NY Times: Health Care Fraud Proves Elusive for Medicare

Fraud has long blighted federal healthcare programs, but even as the government recovers billions of dollars from fraudsters each year, waste and abuse activity continues to elude authorities, reports The New York Times in a recent article

Despite the Obama Administration’s war on health care fraud and the slew of task forces and outside contractors assigned to combat it, fraud continues to weigh on federal programs like Medicare, running up an estimated $60 billion, or 10%, of the program’s costs each year, the article notes. 

Last year, the administration only recovered $4.3 billion, a fraction of what fraud and systematic overcharging run Medicare every year. The blame however, falls not only on the shoulders of the bad actors perpetrating the scenes, but also on agencies like the Centers for Medicare & Medicaid Services (CMS) that are responsible to detect and prevent them.


“But even with the fancy computers and expert teams, the government is not close to defeating the fraudsters,” writes the NY Times. “And even the effort designed to combat the fraud may be in large part to blame.”

One example provided in the article was Medicare’s recent shut down of a successful hotline in South Florida, an area considered a fraud hotbed by CMS. Citing that CMS deemed the hotline was no longer necessary, the NY Times credits it with leading to more than 1,000 fraud investigations and identifying tens of millions of dollars in questionable payments within the last five years.

Trained staff members hired by an outside constructor manned the hotline, answering calls and passing relevant tips to investigators within 48 hours. Now, calls are routed to a general Medicare number, where it can take months for a complaint to be addressed, a recent evaluation of the program revealed. 


But even with the Obama Administration’s nine federal strike forces that earlier this year announced charges against 90 people accused of a total of $260 million in fraudulent billings, the biggest role goes to a network of private contractors who handle payment claims, recovery audits and program integrity measures. 

The outsourcing of major responsibilities has been a longstanding source of frustration even to Medicare officials, both current and former, who said to the NY Times there is little sharing of information among the companies or even with the government. 

“The recovery audit contractors, for example, do not report to the Center for Program Integrity but to another division within Medicare,” the article writes. “When they pass on evidence of possible fraud, a rare occurrence, Medicare often fails to follow up, according to a report by the Office of the Inspector General.” 

Read more at The New York Times.

Written by Jason Oliva

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