Enrolled in Medicare and want to join the ground war against fraud? All you need now is a pen and a pair of reading glasses.
The government estimates that it loses some $60 billion a year to Medicare fraud and waste, and as it gears up to launch its giant healthcare reform program to provide affordable coverage for every American, putting a stop to this is at the top of the agenda. (The Affordable Care Act, known as Obamacare, not only will expand coverage but will also institute reforms meant to lower the cost of the program and make it run more efficiently.)
One of the ways Medicare officials hope to do this is by turning the 50 million beneficiaries of the senior health insurance program into fraud fighters. This summer, Medicare redoubled its efforts to get them involved by redesigning a claims statement, known as the Medicare Summary Notice, with larger print and a streamlined format. The goal is to have seniors pore over these quarterly statements, now arriving in mailboxes, to find errors.
Medicare maintains a website to explain what to look for (stopmedicarefraud.gov) and has a hotline for telephone inquiries (1-800-MEDICARE). There are also private efforts, like AARP's "decoder" pages, that teach recipients how to find mistakes (link.reuters.com/caf62v).
Experts say seniors should look for red flags such as:
- Provider names they do not recognize and have never seen
- Office visits they did not make
- Treatments they did not receive
- Durable medical equipment they do not have
- Prescriptions they do not take
If a senior finds something amiss, the first step is to call the provider. If the provider can't explain a discrepancy, or the senior doesn't want to accuse their caregiver of anything, he or she can report it to Medicare.
Medicare says it crunches all the data, investigates and then moves to get back whatever funds it can through enforcement actions. Over the last four years the government says it has recovered $14.9 billion that way.
For the most part, people do not get any confirmation that their tips lead anywhere. "It takes many drops of water to build a pond," says Sally Hurme, a senior project manager at AARP. "That's a problem because you don't get that instant reinforcement that your report has sent somebody to jail."
NO AMOUNT TOO SMALL
Some calls are turned over to the Senior Medicare Patrol, a government-funded program of 5,000-plus volunteers who help seniors understand their benefits. Volunteers in the program, which began in 1997, offer group presentations and individual counseling sessions to resolve disputes like this.
The money involved in individual cases is typically small, but no amount is too small to be challenged.
"Most are mistakes or misunderstandings. Very rarely do we come across something that looks like fraud," says Rebecca Kinney, a national program manager for the patrols.
Volunteer Tom Badger, a 73-year-old former billing manager for AT&T from Somerville, New Jersey, says his latest case is for $185.03. It involves a woman in his area who saw a charge on her summary notice for visit to a cardiologist that struck her as odd because she had not had an appointment on that date and had never heard of the doctor she was listed as having seen. She called Medicare, and now Badger is doing the legwork to track the provider and resolve the issue.
"I feel like I help every client I get," says Badger, now in his seventh year in the program. While he knows that his victories are not even the tip of the iceberg, he has seen how many calls reported to Medicare can lead to bigger things. Last year, Badger reported a billing irregularity to Medicare involving a healthcare provider and a durable medical equipment supplier, and then watched from the sidelines as law enforcement brought down a multimillion-dollar kickback scheme. They needed multiple reports about the same provider to tie up the case.
Much of the big money is recovered either through law enforcement actions like this or through litigation, often cases filed as a special type of action called a qui tam lawsuit. These lawsuits allow a citizen with knowledge of a fraud to bring a case and get a cut of the award - up to 30 percent, with no cap on the dollar amount. There are a bevy of lawyers who specialize in this area and work on contingency.
Most cases are filed by people with intimate knowledge of the fraud being perpetrated - current or former employees or competitors who know the business. Regular people considering this route should be cautioned that these cases are complicated, take a long time to resolve and might not end up making their lives better even if there is eventually a big payout, says Jeffrey Newman, a qui tam lawyer who practices in Boston.
"To prove fraud, you have to show somebody knew it. You have to have insiders who knew it was going on, and you have to have a lot of specific information to show a pattern," he says.
To encourage more reports of fraud, Medicare wants to offer rewards that can lead to higher payouts for whistleblowers and is in the process of asking Congress to raise rewards to 15 percent of the amount recovered, up to $9.9 million. As it stands, reports that lead to recovery of funds can reap up to $1,000, and Medicare says in a fact sheet that only 18 rewards, totaling $16,000, had been paid out between 1998 and April 2013.
For seniors, the biggest rewards might not have anything to do with the specific recovery of funds, but in helping to hold the line on waste and fraud, says AARP's Hurme.
"I don't think there is any expectation or anticipation that consumers are going to save the day," she says.
But, she adds, "The residual importance is that as people are encouraged to take a look at their Medicare Summary Notices, they are being empowered to be involved in their healthcare."