Healthcare Fraud Hurts Us All

Photo: Emily Metcalf
article top
Photo: Emily Metcalf

BY DAVID SAYEN – People talk a lot these days about the rising cost of healthcare. How much of a role does fraud play in this?

A significant one, unfortunately. The fact is that criminals steal billions of dollars each year from Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). This is taxpayer money that should be going to medical treatment for some of our most vulnerable citizens, including seniors, low income families, and kids.


Fraud hurts everyone by driving up healthcare costs. It also undermines the financial sustainability of federal healthcare programs upon which millions of Americans depend.

What’s the federal government doing to stop it? Plenty, especially with the new tools we have under last year’s health reform law.

For one thing, we’re becoming more proactive about keeping criminals out of federal healthcare programs in the first place. My agency, the Centers for Medicare & Medicaid Services (CMS), has adopted a more rigorous screening process for new providers and suppliers. This is intended to weed out crooks before they can start submitting fraudulent bills to the government.

Under the Affordable Care Act, we can now use sophisticated new technologies and innovative data sources to identify patterns associated with fraud. We also have the authority to temporarily stop enrolling new providers and suppliers when we detect patterns that may indicate a significant potential for fraud.

When there’s a credible allegation of fraud against a provider or supplier, we can temporarily stop payments to them while an investigation is undertaken.

In other words, CMS is moving away from the old “pay and chase” model of doing business – paying out claims and then trying to recover the fraudulent ones.

Of course, we know that most providers – doctors, hospitals, nursing homes, home health care operators, and others – are honest. But we’re becoming more vigilant about the dishonest few. And those who defraud federal healthcare programs will face tougher penalties.

The Affordable Care Act increases the federal sentencing guidelines related to healthcare fraud offenses involving $1 million or more in losses to federal programs. The Act also allows the government to impose stronger civil and monetary penalties against those who commit fraud. And crooks kicked out of one state’s Medicaid or CHIP program will now be kicked out of all states’ Medicaid or CHIP programs.

Is Medicare making progress in the fight against fraud? Yes, we are. For example, the federal government recovered $4 billion last year from people who attempted to defraud seniors and taxpayers. That’s a record amount.

How can individuals help in the fight against healthcare fraud?

If you have Medicare, here are some things you can do:

·       Guard your Medicare and Social Security numbers. Treat them like you treat your credit cards. Criminals use these numbers to send the government bogus medical bills — in your name.
·       Hang up the phone if someone calls and asks for your Medicare number, Social Security number, or bank or credit card information. Medicare will NEVER call and ask for this information, and we will NEVER call you or come to your home uninvited to sell Medicare products.
·       Be suspicious of anyone who offers you free medical equipment or services and then requests your Medicare number. It’s illegal, and it’s not worth it!
·       Don’t let anyone borrow or pay you to use your Medicare ID card or your identity.
·       Check your Medicare claims for errors. Look at your Medicare Summary Notice or statements from your Medicare plan.
·       If your Medicare Summary Notice shows billings for goods or services that you never received, call us at 1-800-MEDICARE (1-800-633-4227). The sooner you see and report suspected fraud, the sooner we can stop it. TTY users should call 1-877-486-2048.

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).





Comments are closed.