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The Size and Scope of Fraud in Medicare
By Nicole Kaeding of Cato.
"Medicare spends more than $600 billion annually, but not all of that money is spent wisely.
Yesterday, I wrote about the Washington Post’s expose
on motorized wheelchair fraud. Records suggest that 80 percent of
motorized wheelchair claims are “improper,” amounting to billions in
waste. Unfortunately for taxpayers, this is just the tip of the iceberg
on Medicare fraud.
The Government Accountability Office estimated that Medicare’s “improper payments” amounted to $44 billion, or 8 percent of total expenditures, in 2012. GAO considers
Medicare a “high risk” program for its “vulnerabilities to fraud,
waste, abuse, and mismanagement.” GAO criticized Medicare for its
inability to control the problem saying that Medicare “has yet to
demonstrate sustained progress in lowering the rates [of improper
payments].”
Other experts believe
that GAO undercounts examples of fraud in Medicare. Malcolm Sparrow of
Harvard University estimates that closer to 20 percent of claims–or $120
billion annually are improper.
Medicare’s lax oversight of its payment system perpetuates the issue.
Millions of claims come in daily and are paid without review or
analysis. Scammers know that Medicare payments will not be scrutinized;
the chance of getting caught is quite low. Scammers simply adapt and
continue finding ways to game the system.
Just yesterday, the Department of Justice announced
that an individual in Louisiana was sentenced to prison for submitting
“unnecessary or never provided” claims to Medicare. The federal
government’s Medicare Fraud Strike Force “has charged nearly 1,900
defendants who have collectively billed the Medicare program for more
than $6 billion” since 2007 illustrating just how widespread the issue
is.
Even with the threat of prosecutions, scammers know that Medicare is
slow to act.
According to John Warren, a former employee in Medicare’s
anti-fraud office, Medicare is hesitant to deny claims. It risks denying
coverage to a legitimate claim, creating a backlog and potential
outrage. Even though the scam cost taxpayers billions, Warren told the Washington Post “looking back, I think we did pretty good.”
These various forces illustrate that Medicare will not be able to
control the problem of fraud without serious reform. As my colleague
Chris Edwards wrote in 2010,
Efforts to combat Medicare fraud frequently fail, and
they can involve a vicious cycle. Cracking down on fraud may open new
opportunities for fraud. And fighting fraud often involves new layers of
complex regulations that may “discourage organizational innovation and
market entry, and [ensnare] innocent providers.” To get out of the
vicious cycle of government health care fraud, we should move toward a
consumer-driven system where patients and providers would have strong
incentives to be frugal with health care dollars and crack down on
waste.
Medicare might have slowed the motorized wheelchair scam, but as long
as the vulnerabilities in Medicare exist, scammers will surely try to
benefit."
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