Medicare Fraud

My father is 72 years old.  When he was 16 he was in a car accident and damaged his knee.  He’s had pain in that knee every day since then.  For the last 10 years his doctor has suggested he have knee replacement surgery.  My dad wouldn’t consider it until last winter, when he had to use a walker to get around.  He’s a little stubborn.

When your parents need Medicare it changes your perspective on the program.  I’ve never paid any attention to it, but now that my parents are older and need it, I’m grateful that they have it.

Medicare fraud has been a problem for a long time, but in the economic conditions we’re all experiencing now of downsizing and budget cuts it’s a big concern.  We can’t afford to use financial resources wastefully or fraudulently.

There are many ways to perpetrate Medicare fraud:

A health care provider bills Medicare for services never provided

A supplier bills Medicare for equipment never provided

Someone uses another person’s Medicare card to get medical care, supplies, or equipment

Someone bills Medicare for home medical equipment after it has been returned

A company offers a Medicare drug plan that has not been approved by Medicare

A company uses false information to mislead you into joining a Medicare plan

The newest incarnation of Medicare fraud is medical scooter fraud.  Scooters, or power wheelchairs, are part of Medicare Part B coverage of durable medical equipment (DME).  They must be medically necessary based on a number of criteria, and a less expensive DME (cane, walker, manual wheelchair) must not be appropriate.

According to records from the Centers for Medicare and Medicaid Services, the cost of motorized wheelchairs to the government health services for senior citizens has risen from $259 million to $723 million from 1999 to 2009.  That’s an increase of 179%!

A report released this month by Medicare’s Inspector General also showed that 61% of the motorized wheelchairs provided to Medicare recipients in the first half of 2007 went to people who either didn’t qualify for them or for whom the claims were not properly documented.  The inspector General reports that Medicare is billed an average of $4,018 for a motorized wheelchair that actually sells for about $1,048.

In May of this year, a Houston jury convicted a patient recruiter of Medicare fraud involving scooters.  Marion Beverly Metoyer was receiving kickbacks in exchange for supplying a DME company with Medicare recipient information to use in billing Medicare for power wheelchairs.

The power wheelchair claims were coded as replacements for wheelchairs lost during hurricanes that hit the Houston area in the fall of 2008 in order to allow submission without doctor’s orders.  As a recruiter, Metoyer went door to door offering Medicare recipients a free wheelchair in exchange for Medicare information.

Metoyer faces maximum penalties of 10 years in prison for health care fraud conspiracy, 10 years for committing health care fraud, 5 years for conspiring to receive illegal kickbacks, and 5 years for receiving illegal kickbacks.

Also in May of this year, a Los Angeles owner of a durable medical equipment company was sentenced to 55 months in prison for a nearly $1 million power wheelchair fraud scheme.  Ajibola Adekeunle Sadiqr was also ordered to pay restitution and serve 3 years of supervised release following his prison term.

Sadiqr purchased fraudulent prescriptions and medical documents in order to submit false claims for expensive power wheelchairs and other DME he claimed he supplied to Medicare beneficiaries.

These cases are examples of the same tried and true Medicare fraud schemes with a new high-dollar product.  In June this year, a Miami psychiatrist pled guilty for his role in a $200 million Medicare fraud scheme.  Two officers of a fraudulent physical therapy company in Miami pled guilty to submitting almost $800,000 of false Medicare claims.  In May, a registered nurse at a home health care agency was convicted of causing the submission of about $230,000 in false Medicare claims.

Medicare fraud affects all of us.  Abuse of the system takes resources out of the system and causes health care costs to rise for all Americans.

Anyone who receives a Medicare-covered service will get a Medicare Summary Notice in the mail every 3 months.  The notice shows all services and supplies billed to Medicare on your behalf, what Medicare paid, and what you owe the provider.  This should be reviewed in detail.  The notice can also reviewed online at any time at www.MyMedicare.gov.

Anyone who suspects Medicare fraud should go towww.stopmedicarefraud.gov for information on reporting the fraud.  The U.S. Department of Health and Human Services (HHS) and U.S. Department of Justice are working together to investigate Medicare fraud.

Everyone I’ve talked to that has had the knee replacement surgery that my dad just had has told me the same thing, “I wish I’d done it sooner.”  My dad isn’t there yet.  I’m hoping for the day where he looks back and says that.  In the meantime, I’m just glad he has Medicare to help him stay healthy and independent.

 

Gina Bliss, CPA, CFE, is a senior manager at EFP Rotenberg, LLP, Certified Public Accountants and Business Consultants, who specializes in internal audit, fraud audit, and forensic accounting.  She may be reached at (585) 295-0536 or by e-mail at gbliss@efprotenberg.com