We all hear about healthcare fraud, that it is rampant, and that not only does it drain huge amounts of needed dollars from Medicare and Medicaid programs, it also is responsible to some extent for the large increases in private healthcare insurance. There is no one that healthcare fraud doesn't affect. If you have insurance, you're subsidizing the fraudsters' lifestyles; if you don't have insurance, fraud is probably one reason you can't afford it.
Rebecca Busch, CEO of Medical Business Associates, explained in her Tuesday presentation at the 20th annual Association of Certified Fraud Examiners' conference that healthcare is a $2 trillion industry, and that the Office of the Inspector General (OIG) estimates that $60 billion is lost each year to fraud.
The OIG is the federal government's watchdog over fraud and waste in government programs. It is on of the few government agencies that has a positive Return on Investment (ROI): for every $1 the OIG invests in healthcare fraud investigations, it gets back $17. Isn't that amazing?
According to Ms. Busch, the areas of concern by the OIG with respect to healthcare fraud are as follows
- payments for unallowable services
- payment for improper services
- improper claims submissions
- manipulation of billing systems (to obtain higher reimbursement)
- gaming through discharge or transfer of patients to facilities for financial, versus, clinical reasons
- unreasonable and not medically necessary services
OIG-identified vulnerabilities are:
- Durable Medical Equipment (DME) suppliers circumventing enrollment and billing controls. DMEs have been identified by both Medicare and Medicaid programs as huge sources of healthcare fraud.
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