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Medicare Fraud Enforcement More Than Window Dressing

Philip Betbeze, for HealthLeaders Media, December 31, 2009

Hopefully all of us are getting some needed R&R over the holidays and are ready to take on the challenges of a new year and a new decade.

Healthcare reform will soon be behind us (at least the legislative portion), and that means the mainstream media will be paying less attention to healthcare issues. That's good news. One year as the top domestic punching bag has likely been enough for most of you. However, even if the media feeding frenzy moves on from healthcare, and however you feel about the way healthcare reform has been handled, some legacies aren't so easily jettisoned.

For instance, take Medicare fraud enforcement. Some have speculated that once President Obama gets his way with healthcare reform, unquestionably his top domestic priority, his administration's focus will stray away from such concerns as Medicare fraud enforcement. In short, I don't think so. Much of the credibility of the new healthcare reform package depends on savings, particularly savings in areas like fraud and abuse, predicted by the president as ways to pay for the increased spending that will be necessary to cover millions of the newly insured.

That's probably a good thing for most of you law-abiding CEOs, because anything lost to fraud means less reimbursement for those who are following the rules.

Just before Christmas, yet another batch of 30 alleged fraudsters in Miami, Detroit, and Brooklyn—including doctors and nurses—were indicted on charges they conspired to bilk Medicare out of $61 million in false claims. That brings to 500 the Medicare fraud body count in less than two years. I know because the Department of Health and Human Services held a press conference to tell us just how successful they've been recently.

On the heels of the indictment news, the Medicare Fraud Strike Force, a partnership between the U.S. Department of Justice and the U.S. Department of Health and Human Services, formed—you guess it—less than two years ago, announced it would expand operations in Brooklyn, Tampa, and Baton Rouge, adding investigators and offices to fraud hotspots like Miami, Los Angeles, Detroit, and Houston.

The President has correctly wanted to seem tough on Medicare fraudsters because any call to increase the government's role in healthcare was predictably met with fingers pointed at the estimated $60 billion lost to fraud annually in the Medicare program.

Medicare fraud—and the predictable outrage over it—is far from a new issue. In fact, the Strike Force was formed in the Bush administration. But the Obama administration is, again correctly, taking a good idea and publicizing every move it makes. That means more press conferences by HHS Secretary Kathleen Sebelius, more perp walks, and yes, more investigations.

To be sure, much of the fraud enforcement up to now has featured "street level fraud," says Bass, Berry and Sims Partner Brian Roark, an attorney who specializes in healthcare law. He means most fraudsters paraded at recent press conferences are the folks who are prospecting for patients off the street to claim benefits they don't require or need, or businesses that set up in a strip mall who provide durable medical equipment to patients who don't need it or to patients that don't exist. "For the most part, there's widespread support for enforcement against this blatant fraud," Roark says.

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