Medicare fraud continues to grow

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The inspector general of the Department of Health and Human Services (HHS) has warned repeatedly that the Medicare program is "highly vulnerable" to fraud, particularly in South Florida, where schemes center on expensive, infusion-based HIV medications and on equipment such as wheelchairs, walkers, canes and hospital beds.

According to The Washington Post, officials from the Centers for Medicare and Medicaid Services (CMS), reported they have stepped up their efforts to combat fraud over the past year by working closely with investigators, removing the requisite billing numbers of nearly 900 companies and imposing new standards in high-fraud areas that would prevent people convicted of felonies from ever receiving a Medicare number.

Law enforcement authorities estimate that healthcare fraud costs taxpayers more than $60 billion each year, reports The Post. In what prosecutors call the largest case of healthcare fraud by a single person, Rita Campos Ramirez of Miami, over nearly four years, electronically submitted more than 140,000 Medicare claims for unnecessary equipment and services.

Healthcare experts said the simplicity of Campos Ramirez's scheme underscores the scope of the growing fraud problem and the need to devote more resources to theft prevention.

"There's always more fraud than we have resources to combat," said Kimberly L. Brandt, director of program integrity at CMS. "We have done a much better job of realigning our resources to attack this problem."

Investigators and prosecutors trained their focus on Miami after noticing two patterns:

  • Nearly half of 1,581 medical equipment companies in the Miami area did not comply with basic Medicare requirements to be open during scheduled hours and to have a telephone number. The inspector general and the Government Accountability Office have flagged weak oversight of these suppliers for about 12 years, according to congressional testimony.

  • The South Florida region bills Medicare more than $2 billion each year for injectable HIV medications—a figure that is 22 times higher than similar claims in the rest of the country, and is out of line with demographic data in a population of 2 million in Miami-Dade County, HHS statistics show.

Officials from the Department of Justice have moved to freeze money in suspicious bank accounts controlled by medical equipment company owners and have created a Washington, D.C.-based strike force to handle the issue.

Since the creation of the strike force, authorities report a $1.75 billion drop in Medicare claims in Miami since the operation began a year ago but continue to look for a more comprehensive solution as the fraudulent medical equipment companies appear to have shifted tactics to other areas, according to Christopher Dennis, the special agent in charge of the HHS inspector general's office in Miami.

According to The Post, Medicare program officials said they are vigilant despite time pressure and limited resources—employees review fewer than 5 percent of the nearly 1 billion claims filed each year. The vast majority of claims shuttle through computer systems that are tweaked when authorities notice fraud patterns.

CMS currently is working to finalize a rule that would prevent convicted felons from obtaining Medicare billing numbers. At present, that regulation applies only in a few high-fraud regions, The Post reported.