Think Medicare. Now think fraud.
We have marshaled Eliot Ness-type teams to hunt it. Earlier this year, a national Fraud Strike Force, comprising 700 personnel, hailing from the FBI, the U.S. Department of Health and Human Services, state attorneys general, and state and local police, issued indictments against 111 individuals for stealing $225 million. Last year Medicare’s fraud-busters recovered $4 billion. The Secretary of HHS estimates that every dollar spent rooting out fraud yields $6.80.
The sobering statistic, though, is the actual extent of fraud, because the figures that end up in the news undercount the crime. Typically, strike forces go after the big perps. They rarely trail the mom-and-pops. It isn’t worth the manpower.
Yet a dismaying number of providers are scamming Medicare and Medicaid.
The scams are drearily familiar. Clinicians bill for services never provided, for more services than provided, or for more complex services than provided. Cagey perps will steal identities from patients. Some patients receive payment, but some don’t know that their clinicians are ripping Medicare off. A patient gets home care for three weeks, not the six weeks billed. Another patient is billed for an elaborate wheelchair, but receives a basic one. Medicare pays for drugs, orthopedic shoes, oxygen that patients don’t need and don’t receive. Generally patients do not suffer: these perps are not operating on wrong body parts. But the crimes are not victimless: the victim is the government-run health insurer and, consequently, the taxpayers.
The perps are physicians, nurses, occupational and physical therapists, pharmacists, health care executives. Without resorting to fraud, they could earn respectable salaries.
The question looms: Why the scams, from people who could prosper without them? Greed plays a role: a fraudulent provider can triple a projected six-figure income. Yet many Americans manage on six-figure incomes.
Perhaps the fraud signals a deeper malaise: low government morale. James Surowiecki (New Yorker, July 11, 2011), in probing why so many Greek citizens don’t pay income taxes, traced the low compliance to the culture. He dubbed the phenomenon “low tax morale.” Citizens simply don’t see the government, and hence its strictures, as important enough to warrant compliance. Furthermore, nonpayers are so rarely punished that most citizens assess the risk of punishment as minimal – which reinforces the low morale.
In the United States, a swath of the electorate now proclaims government as harmful, inefficient, loathsome or unnecessary. As this swath grows, a mindset takes hold: the government payment rules are not important. So a provider, faced with the complicated forms, the changing regulations, the incessant memoranda from Medicare, may well think: who will know? Why not? After all, I’m cheating a harmful, inefficient, loathsome or unnecessary Uncle Sam. Nobody is likely to find out. And my patients won’t complain, even if they sense a billing disparity.
One solution for fraud lies with Eliot Ness-like strike forces. But another tack is to raise “government morale” for all of us, across the electoral spectrum. Fraud flourishes not solely in the hearts of larcenous fraudsters, but in the “we-hate-government” climate that gives people free rein to break the rules.
Medicare is crucial to the health of millions of Americans, and we must recognize it as such. And we must speak out when we suspect fraud. •
Joan Retsinas is the managing editor of Medicine & Health/Rhode Island, a monthly journal of the Rhode Island Medical Society.
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