Health Plans
e-Newsletter
Intelligence Unit Special Reports Special Events Subscribe Sponsored Departments Follow Us

Twitter Facebook LinkedIn RSS

Opinion: An e-ripoff of the U.S.

Los Angeles Times, August 22, 2011

Around the country, a never-ending stream of Medicare and Medicaid rip-off stories suggest many people now use these programs as personal tills. Scores of reports over the last decade catalog completely implausible Medicare and Medicaid claims paid, apparently without a hiccup, for patients who were dead, imprisoned or previously deported from the country and forbidden to return. A significant number of claims involved prescribing physicians who were long-since dead. What makes these healthcare programs so vulnerable to fake billings and at such a scale? It's not so much the healthcare policy itself, nor the program design; the vulnerability stems from the payment mechanism the government has chosen to use. Most Medicare and Medicaid funds are paid out electronically and automatically, in response to electronic claims received from a vast spectrum of providers. Most claims are adjudicated by computers using rule-based systems, with no human intervention at all. Fraud perpetrators have only to learn the rules; then they can submit thousands of claims electronically and with relative impunity. If they get things wrong, they'll receive helpful computer-generated messages explaining their mistake. Those committing fraud find it easy to get paid for fabricated claims because the government's systems check for billing correctness but not for truthfulness. The simple rule for getting rich quick through healthcare fraud is "bill your lies correctly."