Health care fraud rampant in U.S.

Federal authorities announced they recovered $4.1 billion in health care fraud judgments last year, a record high amount which officials on Monday credited to new tools for cracking down on deceitful Medicare claims by hospitals, doctors, physicians, nurses and other trusted professionals within n the system. The fraud is systemic and rampant.

“Yes organized crime is involved but most of the fraud is by people you thought you could trust, doctors and hospitals all gaming the system to essentially rip it off”, says Kevin Booth of Charlotte, N.C, who works for a major hospital system: “You see this kind of fraud especially in the form of up-coding and unbundling of services so the hospitals can charge more to patients and the government, $4 billion is just a drop in the bucket. The problem is its hospital administrators, doctors, medical specialists who are gaming the system, in addition to organized crime”, he said.

In Kansas the problem is very bad, with hospitals routinely overcharging poor and uninsured patients for healthcare services. Its a problem all across the United States, which pays the highest per capita of any nation on earth for healthcare and has one of the worst healthcare outcomes of any industrialized nation. It's tragic!

The recovered funds are up almost 50 percent from 2009. “This is huge, but still not where it needs to be. You have to crack down on hospitals and doctors, which regulators are no so keen to do. They have fallen for the same trap as normal people…Nobody wants to accuse doctors and hospitals of fraud. The presumption is that these are good people. In many cases they are profit driven, which means overcharging for basic services and skimping on care to patients. The problem is the fact that the whole system is designed to make money – that is the wrong motive when it comes to healthcare and helping sick people. In many respects our whole health care system is predatory - where medical providers charge as much money as they can to people, whether they can afford or not. No other country does it like America. No other industrialized nation would allow people to be abused to the extent we do in this country. It hurts sick people the most”, said Vern Anderson of Charlotte, who did medical billing for a major hospital before retiring. “I had to finally get out of it. We would buy band aids for pennies and charge people as much as $15.00 for the same thing, then complain the government wouldn’t reimburse us enough. It made me sick what we did and what we charged people in the hospital I worked at”, he said.

Attorney General Eric Holder and Department of Health and Human Services Secretary Kathleen Sebelius were expected to make the announcement at a news conference Tuesday.

“$4.1 billion is huge”, says Larry Miles of Charlotte. “But it only represents a small amount of the fraud that could be stopped if you could just regulate what hospitals and doctors could charge people”, he said.

“It’s so sad how the people get robbed by others at a time when they get sick in America. I would say it’s un-American but it happens everywhere in the healthcare system. Insurance companies , hospitals, doctors, administrators, nurses, provider networks are all in on it (meaning the fraud)”, said Mary Stickler of Charlotte, who works for a nursing home. “We charge people for everything you can possibly imagine and then some. On some days I just want to cry”, she said

The Department of Justice and the Department of Health and Human Services told The Associated Press that agencies are doing a “better job of screening providers” before they get in the system and have beefed up enrollment requirements.

Now investigators are conducting “site visits” to make sure moderate risk providers have a legitimate office. Higher risk providers are also subject to fingerprint and criminal background checks. This is necessary to insure people are not just stealing wholesale from the system.

“You can’t believe how much fraud there is in the health care system”, says Doreen Moore of Charlotte, a former billing clerk for a group of physicians in the area.

Authorities have long said the solution to solving the nation's estimated $60 billion to $90 billion a year Medicare fraud problem lies in vigorously screening providers and stopping payment to suspicious ones.

“Providers are hospitals and physicians – they are the ones perpetrating fraud on the system. People do not seem to understand that. We want so desperately to trust our local doctor, physician and hospital. After all our life is in their hands, instead they are taking advantage of people in many cases”, says Wendy Quinter of Charlotte. “You can’t trust people who won’t be upfront about what they want to charge you or Medicaid or Medicare”, she said.

They also say it is important to end the antiquated system of paying the claims first then chasing suspicious ones. Too many doctors and hospitals are taking advantage of that to steal from the system. “It’s rampant like a disease”, says Toby Inhofe of Charlotte. “It should make every American hoping made”, he said.

By the time officials catch on to bogus billing patterns, criminals typically dump that provider ID and open a new one, or flee the country.

The Centers for Medicare and Medicaid Services has come under fire for lax screening as violent criminals and mobsters are also getting involved, seeing the fraud as more lucrative than dealing drugs and having less severe criminal penalties. “These are the ones grabbing all the headlines but its hospitals and provider networks that really grab the cash and run up the cost”, said Killian Grey of Charlotte.

Halting Medicare fraud has become even more paramount as the scams that once bilked $1 million or $2 million a decade ago have morphed into sophisticated multimillion dollar networks involving doctors, patient recruiters and patients.

"Fighting fraud is one of our top priorities and we have recovered an unprecedented number of taxpayer dollars," Sebelius said in a statement. "Our efforts strengthen the integrity of our health care programs, and meet the president's call for a return to American values that ensure everyone gets a fair shot, everyone does their fair share, and everyone plays by the same rules."

The size and scope of the fraud is mind boggling!

Federal health officials said Monday they are also doing a better job of sharing data with other agencies but admit they can’t investigate all the fraud and crime in the healthcare system .

Officials credited the spike in recovered funds in part to specialized “strike force teams” set up in fraud hot spots around the country, including Miami, Detroit and Los Angeles but fraud happens everywhere in every place there are doctors and hospitals…The strike force teams charged 323 defendants, who collectively billed the Medicare program more than $1 billion last year, according to various media reports.

That includes a massive bust in February 2011, in which more than 100 doctors, nurses and physical therapists were charged with fraud in nine states. One official who spoke on the condition of anonymity admitted: “The fraud is so wide spread and systemic we just don’t have the resources to go after all the doctors and hospitals. We would need the resources of the entire FBI to do that. I can tell you there is no hospital that doesn’t engage in fraud. If you dig deep enough you uncover it everywhere. We are not allowed to really investigate how skewed the system really is. Our hands are basically tied and we are limited to what we investigate. The whole system is corrupted, I just am not allowed to say it publically”, the official said.

Stopping Medicare's budget from bleeding that cash is critical to paying for President Barack Obama's health care overhaul. Sadly the President is being undermined by the Republicans in Congress who have received money and political donations from insurance lobbyists and Political Action Committees which fight to insure the system stands as it is.

“The motive is money and profit based medicine, which mean patients get short changed and the government gets over charged. You ask any medical student today why they get into medicine and the number one reason is to make lots of money”, said Wilma Noor of Charlotte, N.C.

Department of Justice officials noted that judges are under intense pressure by doling out longer prison sentences. The average prison sentence in fraud cases was more than 47 months in 2011, compared to 42 months the previous year. “It’s still not enough to stem the fraud inside the system”, said Doug Copeland of Charlotte. “Lets face it there is not enough jail space to keep the doctors, and physician, hospital administrators, board members who are engaged in the overcharging of patients in the Medicaid/Medicare system”, he said.

To fix the system would require more reform than the President has proposed and Republicans will ever allow. There is too much PAC money out there, too many Congressmen on the take to special interest for us to do what is necessary to fix the system. $4 billion in savings is only a percentage of what can be saved if we were serious about fixing the system. In the meantime we will take what we can get and hope the feds will do what is right and investigate more cases of fraud…

Robert Tilford

LaCrosse, Kansas