Medicare Claims Database Highlighting Fraud and Abuse

November 18, 2010 (Press-News.org) According to The Wall Street Journal, almost every person age 65 and older is insured by Medicare. While most doctors and providers use the system properly, incidence of Medicare fraud and abuse cost taxpayers billions of dollars every year.

The federal government notes that errors in the Medicare program are typically the result of billing mistakes and not an attempt by a doctor or company to improperly bill the program. According to the Centers for Medicare and Medicaid Services, the program made nearly $24 billion in improper payments in 2009, almost doubling the previous years' rate.

The price of fraud, however, runs even higher. A CBS report notes that Medicare fraud costs taxpayers an estimated $60 billion a year, and some estimates put the figure at nearly $100 billion.

Common Types of Fraud

According to Medicare.gov, the official government Medicare site, common types of Medicare fraud include patients being charged for services they never receive, or being billed for equipment or services they do not need. Fraud can also involve doctors using another person's Medicare card to bill for services or companies billing for home equipment that has been returned.

There have been some high-profile cases of fraud recently. The New York Times reported that 40 members of an organized crime family were arrested and charged with stealing the identities of numerous patients. These identities were then used to bill out nearly $100 million in Medicare costs to clinics in 25 states. And in Miami, the management at a chain of mental health clinics was charged in a $200 million Medicare scheme in which patients were billed for group therapy sessions that never happened.

Medicare Claims Database

A recent Wall Street Journal report details the practice of one New York City physician who billed out and was paid more than $2 million from the Medicare system in 2008. While the doctor practiced family medicine, she repeatedly billed the program for extraordinary procedures that are uncommon in a family practice, including "polysomnography sleep analyses, nerve conduction probes and needle electromyography procedures." As a result, she was one of the highest paid family medicine practitioners in the system.

The Journal gathered this information from the Medicare claims database, which houses information on payments made by the Medicare program. Though payments made to individual doctors remain confidential, the database does show the amounts paid for services to hospitals and other institutional providers. The report notes that this prevents the public from knowing how Medicare spends one-eighth of its funds, over $62 billion in 2009.

But some argue that the database is misused and that the information, including doctor's payments, should be fully disclosed. This disclosure would let the public know where and how fraud and abuse affect the $500 billion program.

Article provided by Powers & Santola, LLP
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