Better weapons for Medicare-fraud battle

Posted: Sunday, January 30, 2011

The following editorial first appeared in the Miami Herald:

On Jan. 13, Renier Vicente Rodriguez Fleitas was sentenced to three years in federal prison for conspiring to bilk Medicare through his Hialeah, Fla., pharmacy. In his plea deal, Rodriguez admitted that he billed about $1.8 million in false claims under Medicare Part D. He was ordered to repay $135,930, what he received in reimbursements, to Medicare.

This most recent Medicare-fraud case was chump change by Miami standards. We are the nation’s Medicare-fraud capital, after all, where millions of federal health-care dollars have been stolen in some spectacularly brazen cases.

Still, Rodriguez’s repayment will be counted as stolen Medicare funds recovered this year by the federal government, which in 2010 retrieved $4 billion in fraud judgments. That’s a record high — up by 50 percent from 2009. Good news, right?

More like a drop in the bucket. Authorities estimate that Medicare fraud bilks the U.S. government as much as $60 billion to $90 billion a year. Of that, Miami accounts for about $3 billion. Medicare scams have become so lucrative, the FBI says, that the mob is getting in on them.

Much of the fraud stems from inadequate screening of providers and an antiquated system that pays up front, then must backtrack to weed out fraudulent claims through what authorities call the “pay and chase” process. By the time the fed’s creaky system catches up with suspicious billing patterns, many crooks have already opened new accounts. Or they take their illicitly gotten millions and leave the country.

The U.S. Health and Human Services Department and the Justice Department have deployed task forces to Miami and other trouble spots to root out fraud. This is paying off. Arrests are up, and recovery of wrongful payments has increased.

In 2010, the FBI investigated a record 2,600 Medicare fraud cases and helped dismantle more than 60 fraudulent firms, some in Miami. Still, the real answer lies in preventing crooks from tapping into the Medicare system at all.

Now federal officials say they have more modern tools to fight fraud thanks to the often-maligned Affordable Care Act. HHS Secretary Kathleen Sebelius calls the act one of the toughest anti-fraud laws ever.

New technology will scrutinize Medicare payments at a timelier rate and flag suspicious patterns. More-comprehensive background checks, possibly including fingerprinting providers, may be coming, Ms. Sebelius says.

What’s with “may” come? These steps should be mandatory — although that would likely require more staff and equipment. The agency that checks providers — the Centers for Medicare and Medicaid Services — gets roughly 18,000 applications a month from would-be providers. Adding staff to weed out the bad guys before they get into provider programs would certainly cost less than the billions stolen each year.

The new healthcare law allows the agency to put a moratorium on new applications in certain fields, say, certain type of medical equipment, if it sees an increase in fraudulent cases there.

Medicare fraudsters are getting better at finding new scams to bilk Uncle Sam. The new anti-fraud tools should include mandatory fingerprinting for providers. Federal agencies that fight Medicare cheating have to be nimble enough to outwit the scammers.

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