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Five Ways Health IT Leaders Can Fight Medicare Fraud

Gienna Shaw, for HealthLeaders Media, March 5, 2010

Fair warning to health IT professionals: Harry Markopolos, the man who infamously warned the government that Bernie Madoff was up to something fishy, is setting his sights on Medicare fraud. And the first place he'll look for evidence is in your system's e-mails, documentation, and databases.

When Markopolos, who now works full-time investigating fraud, looks into a case, he always starts with the IT department. What does he look for? Bills submitted to Medicare by dead patients or from dead doctors, up-coding or billing for procedures that were not performed, and other fraudulent billing practices. He'll check your books for evidence of kickbacks, slush funds, and sudden inexplicable increases in revenue.

In a keynote session at the HIMSS conference in Atlanta Thursday, neurosurgeon and CNN medical expert Sanjay Gupta, MD, interviewed Markopolos about ferreting out fraud and waste in the healthcare system.

The government will increase investigation and enforcement, Markopolos said. And if they find evidence of fraud, it will be the IT professional's "worst nightmare," he says.

They'll start by shutting down your server farms and taking every piece of data they can find. Worse, they might let you think they overlooked some data, just to see if you'll produce it later upon request.

The cost of fraud

Estimates of the cost of Medicaid fraud range from $40 billion to $80 billion a year. The truth, said Gupta, is probably somewhere in between. "Fraud is everywhere, for sure," he said. And it affects "every taxpaying citizen of the United States."

It's "very common" for Medicare to get fraudulent claims from criminals posing as dead doctors, Markopolos said. Another problem—claims for an illness that does not fit with the patient's gender, such as a prostate exam for a woman.

"That's a problem," he said. (Or, suggested Gupta, men coming in for pregnancy treatment. "That's a bigger problem," Markopolos quipped.)

While Wall Street fraud robs investors of their money, Medicare fraud endangers lives and steals taxpayer dollars, Markopolos said. When a large healthcare organization is making money for illegitimate reimbursement claims, it harms other organizations that are playing by the rules.

"Medicare fraud is so pervasive, said Markopolos. "The risks of getting caught are so low and the return is so high."

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