The Department of Health & Human Services (HHS-OIG) is targeting fraud in the Medicare program, as such deceit comes with a high cost to taxpayers.
Attorney General Eric Holder and HHS-OIG Secretary Kathleen Sebelius visited Philadelphia on June 17 to participate in the sixth regional health care fraud prevention summit. Those present at the summit were from federal, state, and local partners, beneficiaries, providers, and other interested parties, with the intent of learning innovative ways to eliminate fraud in the health care system.
The summit is in part a larger effort by the administration to root out waste, fraud, and abuse.
Sebelius announced that on July 1, HHS started using innovative forecasting technology to identify Medicare claims on a nationwide basis, and stop claims before they are paid. The system is built on top of new anti-fraud tools and resources provided by the Affordable Care Act.
“But we know that one of the most effective and direct steps we can take to improve Medicare’s long-term health is ridding the program of waste, fraud, and abuse,” said Sebelius, at the Senior Medicare Patrol National Conference on Aug. 9. “For the last 14 years, the Senior Medicare Patrol has been on the front lines of that fight.
“That’s why more than 4.1 million beneficiaries have taken advantage of the Senior Medicare Patrol’s one-on-one counseling or group education sessions. It’s why your community outreach events have reached almost 25 million people,” said Sebelius.
One of the reasons Medicare has attracted con artists and dishonest providers is “because seniors are the majority population who are beneficiaries, and they are worried about their benefits; because Medicare can be very confusing so scam artists can use this as a tool,” said Ginny Paulson, director of SMP Research Center, in a telephone interview.
Paulson added, “Because in the past Medicare had agreed to pay providers based on a ‘pay and chase’ culture and climate, within 30 days of services rendered, so that the providers were willing to participate. This allowed some to abuse the system.”
For example, a Los Angeles jury convicted two church pastors and their employee of stealing $14.2 million from the program. The conspirators had fraudulent durable medical equipment (DME) supply companies.
The pastors opened four different companies to perpetrate their fraud, and recruited parishioners from their church to help carry out the scheme. They were convicted of conspiracy and health care fraud on Aug. 9.
In another recent case in Louisiana, four individuals were convicted in a $4.7 million fraud scheme.
The owner of a Baton Rouge, La., durable medical equipment company, a medical doctor, and two patient recruiters were convicted on Aug. 16. Nnanta Felix Ngari, Dr. Sofjan Lamid, Henry Lamont Jones, and Ernest Payne were found guilty of conspiracy, and taking kickbacks.
Unique Medical Solution Inc., a Baton Rouge-area company owned by Ngari, specialized in providing power wheelchairs to Medicare beneficiaries. Beginning in late 2003, Ngari paid recruiters to locate and solicit beneficiaries to attend health fairs hosted by Jones and Payne at churches.
Doctors present at the health fairs would prescribe the beneficiaries power wheelchairs that were medically unnecessary while all involved parties received kickbacks on the wheelchairs, according to the Department of Justice.
Just during the first half of 2007, $95 million dollars was spent on power wheelchairs that were medically unnecessary, according to evidence in the trial. According to HHS-OIG, recipients of the wheelchairs paid four times the average amount for them.
About 8 percent of the claims were miscoded, meaning suppliers billed Medicare using codes that did not match the model information on the invoices. In addition, a total of 60 percent of claims did not meet Medicare coverage requirements, meaning they should not have been paid by Medicare.
Attorney General Eric Holder and HHS-OIG Secretary Kathleen Sebelius visited Philadelphia on June 17 to participate in the sixth regional health care fraud prevention summit. Those present at the summit were from federal, state, and local partners, beneficiaries, providers, and other interested parties, with the intent of learning innovative ways to eliminate fraud in the health care system.
The summit is in part a larger effort by the administration to root out waste, fraud, and abuse.
Sebelius announced that on July 1, HHS started using innovative forecasting technology to identify Medicare claims on a nationwide basis, and stop claims before they are paid. The system is built on top of new anti-fraud tools and resources provided by the Affordable Care Act.
“But we know that one of the most effective and direct steps we can take to improve Medicare’s long-term health is ridding the program of waste, fraud, and abuse,” said Sebelius, at the Senior Medicare Patrol National Conference on Aug. 9. “For the last 14 years, the Senior Medicare Patrol has been on the front lines of that fight.
“That’s why more than 4.1 million beneficiaries have taken advantage of the Senior Medicare Patrol’s one-on-one counseling or group education sessions. It’s why your community outreach events have reached almost 25 million people,” said Sebelius.
One of the reasons Medicare has attracted con artists and dishonest providers is “because seniors are the majority population who are beneficiaries, and they are worried about their benefits; because Medicare can be very confusing so scam artists can use this as a tool,” said Ginny Paulson, director of SMP Research Center, in a telephone interview.
Paulson added, “Because in the past Medicare had agreed to pay providers based on a ‘pay and chase’ culture and climate, within 30 days of services rendered, so that the providers were willing to participate. This allowed some to abuse the system.”
For example, a Los Angeles jury convicted two church pastors and their employee of stealing $14.2 million from the program. The conspirators had fraudulent durable medical equipment (DME) supply companies.
The pastors opened four different companies to perpetrate their fraud, and recruited parishioners from their church to help carry out the scheme. They were convicted of conspiracy and health care fraud on Aug. 9.
In another recent case in Louisiana, four individuals were convicted in a $4.7 million fraud scheme.
The owner of a Baton Rouge, La., durable medical equipment company, a medical doctor, and two patient recruiters were convicted on Aug. 16. Nnanta Felix Ngari, Dr. Sofjan Lamid, Henry Lamont Jones, and Ernest Payne were found guilty of conspiracy, and taking kickbacks.
Unique Medical Solution Inc., a Baton Rouge-area company owned by Ngari, specialized in providing power wheelchairs to Medicare beneficiaries. Beginning in late 2003, Ngari paid recruiters to locate and solicit beneficiaries to attend health fairs hosted by Jones and Payne at churches.
Doctors present at the health fairs would prescribe the beneficiaries power wheelchairs that were medically unnecessary while all involved parties received kickbacks on the wheelchairs, according to the Department of Justice.
Just during the first half of 2007, $95 million dollars was spent on power wheelchairs that were medically unnecessary, according to evidence in the trial. According to HHS-OIG, recipients of the wheelchairs paid four times the average amount for them.
About 8 percent of the claims were miscoded, meaning suppliers billed Medicare using codes that did not match the model information on the invoices. In addition, a total of 60 percent of claims did not meet Medicare coverage requirements, meaning they should not have been paid by Medicare.
