Medicare Fraud: Winning the Battle

Some physicians, health care executives and beneficiaries in Detroit and Miami have something in common:  They are being charged with Medicare fraud. 

One physician in Miami has already been convicted and sentenced to 97 months in prison for a $10 million Medicare fraud scheme.  Eight Miami area residents are charged with Medicare fraud in a $22 million scheme to bilk the Home Health Care program funded by Medicare.  In Detroit, 53 physicians, health care executives and beneficiaries are charged with false billing to the tune of $50 million.  

Billions of dollars are stolen from the Medicare fund, and ultimately US taxpayers, every year by a few physicians and health care providers lacking integrity in providing responsible health care. The fraud is found mostly in false billings, and sometimes even the ‘beneficiaries’ participate in lying about their conditions.

The Center for Medicare Services (CMS) Internet site says, “Medicare fraud affects every American. Not only is waste, fraud and abuse taking critical resources out of our health care system, it contributes to the rising cost of health care for all Americans and harms the short-term and long-term solvency of these essential programs.”

It stands to reason then that eliminating fraud should be a top priority for the Obama administration.  And it is. 

The Departments of Health and Human Services and Justice are collaborating to investigate and try to eliminate fraudulent health care professionals who try to cheat the system.  Because two departments are working together, they are able to not only identify and prosecute cheaters, but they also can do some prevention work.  Their efforts focus on stopping those who perpetrate fraud by

  1. Continuing to utilize Strike Force teams that fight fraud in Miami and Los Angeles;
  2. Creating Strike Force teams in Detroit and Houston; and  
  3. Helping State Medicaid officials conduct provider audits and monitor activities to detect   fraudulent activities.
  4. Using modern technology to complete in a matter of days analysis of electronic evidence that previously took months to analyze using traditional investigative tools.

Prevention work will address

  1. Building demonstration projects focused on Durable Medical Equipment. These projects will increase site visits during enrollment so we can block out impostors and make sure criminals aren’t posing as real providers;
  2. Increasing training for providers on Medicare compliance and offering providers the resources and the knowledge they need to help identify and prevent fraud;
  3. Improving data and information sharing between the Center for Medicare & Medicaid Services and law enforcement so we can identify patterns that lead to fraud.
  4. Strengthening program integrity activities to monitor and ensure Medicare Parts C (Medicare Advantage plans) and D (prescription drug programs) compliance and enforcement; and
  5. Working with citizens to identify fraud via hotlines and Web sites.  (   

Bottom line, eliminating fraud will cut costs for families, businesses and the federal budget and increase the quality of services for those who need care.  It is incumbent upon all of us to support these national efforts.