Medicare Fraud: Saving Innocent Medical Professionals from Getting Convicted

The US Congressional Budget Office estimates that in 2010, about $528 billion was spent by the government for Medicare, a Federal health insurance program designed to benefit the elderly (at least 65 years old), certain younger Americans with disabilities, and those suffering from End-Stage Renal Disease (ERSD), which is a permanent kidney failure that requires dialysis or a transplant. About $47.9 billion of what was spent, however, is believed to have been paid to fraudulent claims, according to the US Government’s Office of Management and Budget – a belief that turned out to be erroneous as part of the amount has actually been paid to valid claims.

There are two governmental programs designed to provide medical and health-related services to particular groups of people in the US: Medicaid and Medicare. Though each program differs with regard to their beneficiaries, both fall under the management of the Centers for Medicare and Medicaid Services, one of the branches of the US Department of Health and Human Services.

Medicare, specifically, has two parts: Part A, known as Hospital Insurance (HI); and, Part B, called the Supplementary Medical Insurance (SMI). Hospital Insurance (HI) pays for qualified beneficiaries’:

  • Hospital stay, which includes a semi-private room, meals, medical tests and supplies
  • Medically required home health care, which is provided on a part-time basis and which may include speech, occupational, and physical therapy
  • Care in a skilled nursing facility
  • Certain medical equipment, like a wheelchair or a walker which a disabled or an aged beneficiary may require

Supplementary Medical Insurance (SMI) or Medicare Part B, on the other hand, pays for the following:

  • visits to doctors and outpatient hospital visits
  • cost of home health care
  • services medically required by the aged and the disabled, like: services provided by doctors and nurses; X-rays, diagnostic and laboratory tests; renal dialysis; chemotherapy; blood transfusions; certain types of vaccinations; ambulance transportation and outpatient hospital procedures; eyeglasses and prosthetic devices; and, medical equipment, such as wheelchairs, scooters, walkers, and canes

Sources of Medicare funding include monthly premiums from those who enroll in the program, annual deductibles, and payroll taxes collected through the Self-Employment Contributions Act and the Federal Insurance Contributions Act (FICA). Money collected is placed in a trust fund where the government gets the necessary amount to pay hospitals, doctors, and private insurance companies. But while the program’s intent is to help, first, the American public by paying for the cost of the medical and health-related services provided to them and, second, honest doctors who provide medical services to the needy, many medical professionals saw it as an opportunity to extract money from the government through fraudulent claims; specifically, by billing the government for services that were not actually performed, medical services and equipment that were not really provided to patients, and other acts of fraud. Despite the differences in acts, Medicare fraud is directed only on one goal: collect payments from the Medicare program illegitimately.

The billions of dollars that the government loses due to fraudulent Medicare claims has spurred the government to still intensify the fight against Medicare fraud, to the point, however, of suspecting fraud where there is actually none.

While suspicion of fraud may easily be reported to the Office of the Inspector General, those reported, but who are actually not guilty, can suffer loss of patient trust and professional credibility according to the website of Kohler Hart Powell, SC.

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