need to add title here

The $60 Billion Fraud

October 25, 2009 5:00 PM

Medicare and Medicaid fraudsters are beating U.S. taxpayers out of an estimated $90 billion a year using a billing scam that is surprisingly easy to execute. Steve Kroft investigates

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by Treadlightly2 November 15, 2009 1:08 AM EST
Back from a great day at the capitol in Austin; was one of a group who rallied and affirmed the necessity of the drive toward health insurance reform by the end of the year. People from all over the state. It's great to be with people who care/work for all our fellow citizens...so proud to be an American and a Texan and to know such folks. This is the umbrella of diversity that makes us strong. Best to everyone.
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by Treadlightly2 November 14, 2009 8:30 PM EST
It's important to remember that the German government doesn't provide health care or finance it directly. It does regulate insurance companies CLOSELY ? the nonprofits in the main system and the for-profits. The government also requires insurers to keep costs down so things don't get too expensive.
Germans pay 8% of their income and employers match that.
Germans pay 8% of their income and employers match that.

Our system of healthcare is BROKEN BEYOND REPAIR.
We need to stop thinking that socialism is ALWAYS a bad thing.
Do a little research and the evidence is right there.
Our current system is going to bankrupt the country and in the meantime
we get to watch these criminals STEAL TWELVE PERCENT OF $500,000,000,000

SNAP OUT OF IT...GET INVOLVED...WE CAN NOT WAIT TO ACT ON THIS ISSUE
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by rlbarnett48 November 9, 2009 11:47 PM EST
If the Government needs help in this matter, I for one am looking for a job. I do have some investigative experiance from my past & would look forward to having a secure job. Send me an email, rlbarnett48@comcast.net
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by patriotfemale November 6, 2009 8:51 PM EST
I am in the DME industry...in order to bill Medicare, you must have a site visit before they issue a PTAN and you must have an NPI number. It is a shame that Medicare inspectors are unable to discern criminal intent prior to issuing these necessary numbers for billing. There are many legitimate business out there with a mission to help those who truly need it. It is ridiculous that these criminals are hurting Medicare patients and legitimate providers. Medicare needs to get a clue!
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by neilscomment November 3, 2009 5:41 AM EST
All we need or this country needs is common sense.
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by dmacaoda November 2, 2009 9:50 AM EST
Until such time as we can feel confifent that we have eliminated most of the waste and fraud in Medicare; we simply cannot move forward with any plan to dramatically increase the spend level - aka HC reform.

Claims that the cost of HC reform will be paid for via savings in Medicare are a combination of bold faced lies or incompetence.

1 - Medicare fraud and waste is both rampant and out of control - this 60 minutes piece does a nice job of touching on the problem - but instead of a few minutes out of 1 hour TV Show; if the Amertican people could get a days worth of reporitng and examples they would be nauseated and HC reform would be DOA.

2 - Current Medicare reimbursement rates do not pay the actual cost of care. Claims that savings will be forthcoming by reducing Medicare reimbursement is not only false but if enacted will actually cost the taxpayer more. Shortfalls caused by falsely low reimbursement rates get passed along to private payers - not right to begin with, but the result is that this inequity creates more public pay patients. There are law firms who counsel clients on how to shed assets (to their family) so they can go into nursing homes on the government lam.

With proposed changes in HC, especially if a public option is put into play, the cost projections are woefully short as it does not anticipate properly the additional incentives/enrollments that will take place once the "market" defines itself. This is actually what happened in the cost of providing nursing home care (population less than 2 million). Now expand that into hospitalization and medical care across and now how do you spell scary.
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by robreale November 1, 2009 2:10 PM EST
Hello, I would like to let CBS News know that I have called Medicare about charges I did not recognize in the past and was blown off by the service people I spoke to. I was essentially told that I would not always recognize the name and address of the provider (it was in California, I live in NY) and not to worry about it.

Thanks to your story I will do my part as an American in the future and be a real pain in the butt and seek a thorough investigation to make sure those charges are indeed valid!

It's funny because I'm a big Obama supporter who thought he was being quite absurd in his talking points about eliminating waste and fraud in the system, and clearly he has proven again that he knows more than I do. (Thank goodness for that.)
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by LegalInjustice November 1, 2009 8:07 AM EST
Who else is committing Medicaid Fraud?

Florida Medicaid Fraud Control Unit (MFCU) closes 1270 cases, but Only SEVEN percent (88 cases) result in Convictions or Settlements.

The other 1182 cases (93 percent) were unfounded, lacked evidence or closed for various reasons. These numbers are from July 2005 through February 2007 and show cases were opened without a review to determine the validity or viability of a complaint or allegation.

This has been an on-going problem in Florida and was first brought to our attention on January 29, 2003. Florida AG Charlie Crist, who at the time was overseeing the MFCU, received a letter from the U.S. Department of Health and Human Services (HHS). The letter states the MFCU was cited for not providing complete and accurate case information, employing individuals who did not meet established minimum qualifications and ten other deficiencies. The Florida MFCU was placed on high risk and probation for a year.

On December 29, 2008 in the Annual Report on the States Efforts to Control Medicaid Fraud and Abuse the question is finally answered to why the number of cases unfounded or had no evidence were high. This was taken from the report.

-Prior unit policy called for the opening of an operational case, whenever possible, based upon the mere receipt of a complaint. There was little, if any, review to determine the validity or viability of a complaint or an allegation. Case openings will now occur only when there is a criminal or civil predicate that warrants further investigative activities.- Submitted to Governor Charlie Crist on December 29, 2008. see Page 3 Under "Complaints" http://ahca.myflorida.com/docs/2008_Fraud_and_%20Abuse%20Binder_signed.pdf

I was surprised to learn the MFCU had been opening thousands of cases without evidence for at least the last six years. I am not an attorney, but it would seem to violate a persons constitutional right to be arrested without probable cause or verified evidence.

In addition, these innocent people would be used as a pawn to increase the number of arrests made by the MFCU. The increased arrests would help the MFCU get off probation, obtain additional federal funding, receive media coverage and help elect Charlie Crist.

Information obtained in this comment can be found in the my florida, Auditor General section.

1 Auditor General, Department of Legal Affairs, Medicaid Fraud Control Unit, Report No. 2004-033, Reporting Period 07/2001 through 01/2003. http://florida-injustice.com/Support/audit2003.pdf

2 Auditor General, Department of Legal Affairs, Medicaid Fraud Control Unit, Report No. 2006-028, Reporting Period 02/2004 through 01/2005. http://www.myflorida.com/audgen/pages/pdf_files/2006-028.pdf

3 Auditor General, Department of Legal Affairs, Medicaid Fraud Control Unit, Report No. 2008-012, Reporting Period 07/2005 through 02/2007. http://www.myflorida.com/audgen/pages/pdf_files/2008-012.pdf

4 Author's story. http://www.florida-injustice.com/
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by forgood October 30, 2009 4:42 PM EDT
Mr. Rooney is correct. For last year I had a similar experience, but I was in the ER when a doctor looked around the curtain and asked why I came to the ER and said she would return. I knew she wouldn?t because she was not the first doctor to do this after they heard that I had a private doctor who was on the way. They were trying to make money before my doctor arrived. She did not touch me, but billed my insurance over $1,000. When I was told that I would be admitted for observation yet hours went by with them claiming to be trying to find me a room, I knew they would hold me in the ER for 24 hours so the ER could bill my insurance for one full day. When my doctor arrived, he did not seem please with some of the test they ran nor how long I had been in the ER. He said that he was trying to get me into a room as soon as possible. Yet in exactly, 24 hours, the ER staff allowed me to be taken to my room. The nurses on the ward said that it was a shame that they kept me in the ER that long. My room was ready for hours as I also confirmed from my roommate.

As is well known and documented, a lot of elderly and disabled people are too weak to receive expensive treatments, so their health is monitored and maintained with drugs, food and exercise. There is a country that pays more money for wellness care than they do for the care and treatment of sickness.

I was told that the Las Vegas Russian mafia is running a ring just like ones presented in your story.

And all the money the government is currently paying out is too often behind the Department of Social Services and its army of social workers, doctors, nurses, lawyers and judges, etc., who build up false cases in order to hold elderly and other disabled in facilities against their and their loved ones wishes. Often times, these patients are tortured by abuse, neglect and poor medical care and well known by all to die sooner in such captivity. This has been going on for years. Just before leaving office in 2009, check out to see about Pres. Bush passing a law affording these contractors the same protection as Federal employees enjoy and making it harder to receive your loved ones medical records from them.

As long as all of this is allowed to continue, any health care plan will fail and bankrupt the U.S. in the process.
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by mkfarnam October 30, 2009 4:28 PM EDT
Patients signitures should be required!
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by mkfarnam October 30, 2009 4:26 PM EDT
Patients signitures should be required!
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by stopfraudnow October 30, 2009 12:43 PM EDT
Why not equip the auditors to examine 100% of the transactions in minutes rather than weeks? 95 of the fortune 100 have used data analytics to independently verify the accuracy of company transactions. The medicare system needs to be run like an accountable business! We could catch "Tony" by reviewing accounts based on procedure codes submitted vs. national averages: eg; are more expensive procedures being done than normal? Once we catch "Tony" we take his list and run every person on it compared with every other transaction in the whole healthcare system. That gives you every other illegal transaction from fraudsters who bought the same list as "Tony". The Pentagon used ACL (see www.acl.com) to recover $1.4 Billion USD in defense fraud last year. Does the government care more about bombs or hospitals? Lets use the same technology to clean up healthcare now! There is enough waste in the system to provide coverage for every uncovered citizen in the country! Provide coverage for the poor by catching crooks, what's wrong with that?

Erik B
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by stopfraudnow October 30, 2009 12:42 PM EDT
Why not equip the auditors to examine 100% of the transactions in minutes rather than weeks? 95 of the fortune 100 have used data analytics to independently verify the accuracy of company transactions. The medicare system needs to be run like an accountable business! We could catch "Tony" by reviewing accounts based on procedure codes submitted vs. national averages: eg; are more expensive procedures being done than normal? Once we catch "Tony" we take his list and run every person on it compared with every other transaction in the whole healthcare system. That gives you every other illegal transaction from fraudsters who bought the same list as "Tony". The Pentagon used ACL (see www.acl.com) to recover $1.4 Billion USD in defense fraud last year. Does the government care more about bombs or hospitals? Lets use the same technology to clean up healthcare now! There is enough waste in the system to provide coverage for every uncovered citizen in the country! Provide coverage for the poor by catching crooks, what's wrong with that?

Erik B
Reply to this comment
by LegalInjustice October 30, 2009 4:01 AM EDT
Who else is committing Medicaid Fraud?

Headline. Florida Medicaid Fraud Control Unit Closes 1270 cases.
Subheading. But Only Seven percent (88 cases) result in Convictions or Settlements.

The other 1182 cases (93 percent) were unfounded, lacked evidence or closed for various reasons. These numbers are from July 2005 through February 2007 and show cases were opened without a review to determine the validity or viability of a complaint or allegation.

This has been an on-going problem in Florida and was first brought to our attention on January 29, 2003. Florida AG Charlie Crist, who at the time was overseeing the MFCU, received a letter from the U.S. Department of Health and Human Services (HHS). The letter states the MFCU was cited for not providing complete and accurate case information, employing individuals who did not meet established minimum qualifications and ten other deficiencies. The Florida MFCU was placed on ?high risk? and probation for a year.

On December 29, 2008 in the Annual Report on the State?s Efforts to Control Medicaid Fraud and Abuse the question is finally answered to why the number of cases unfounded or had no evidence were high. This was taken from the report.

?Prior unit policy called for the opening of an operational case, whenever possible, based upon the mere receipt of a complaint. There was little, if any, review to determine the validity or viability of a complaint or an allegation. Case openings will now occur only when there is a criminal or civil predicate that warrants further investigative activities.? Submitted to Governor Charlie Crist on December 29, 2008. see Page 3 Under "Complaints" http://ahca.myflorida.com/docs/2008_Fraud_and_%20Abuse%20Binder_signed.pdf

I was surprised to learn the MFCU had been opening thousands of cases without evidence for at least the last six years. I am not an attorney, but it would seem to violate a person?s constitutional right to be arrested without probable cause or verified evidence.

In addition, these innocent people would be used as a pawn to increase the number of arrests made by the MFCU. The increased arrests would help the MFCU get off probation, obtain additional federal funding, receive media coverage and help elect Charlie Crist.

Information obtained in this comment can be found in the my florida, Auditor General section.
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by stuart-johns2 October 29, 2009 6:16 PM EDT
Oh course, private insurance has far more of this going on than does any government program. That's one reason your rates are so high - that and their greed.
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by fitzbender46 October 29, 2009 3:31 PM EDT
A modest proposal: investigative journalists should no longer waste their breath and ask 'why did you not uncover this fraud?'. From the lowliest township clerk, to the head of the SEC, the standard answer is always 'we're underfunded, understaffed and overworked'. How many more people, and how many additional billions, would it take for these employees (of ours!) to actually do the job they've been hired to do??
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by muldrin October 29, 2009 2:00 PM EDT
I wonder if the three dolts that do field inspections bother to look in the phone book to obtain addresses of these medical suppliers. You go to the location during office hours, knock on the door. If no one answers you place them on the "do not pay list". No illigitimate medical suppliers will ever protest this and bring attention to themselves. If 85% of them are phoney it shouldn't be too difficult. And how much do they pay this lady who hasn't thought of doing this? And if we do pass a national health bill we can let these idiots hire the fraud security task forces needed to protect the billions that will be spent on this farse. I can't believe this nightmare.....or the people that are in favor of it....
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by Mokelumne October 29, 2009 11:26 AM EDT
About 10 years ago after being seen by a cardiologist for a routine outpatient procedure, the medicare billing statement I received included a non-existant pace maker implant and hospital stay. I contacted the number on the medicare statement to apprise them of this and encountered a "oh thanks for telling us" and end of story kind of attitude. I actually had to insist that they take a report of these facts starting with my name! I have since learned of many others in my small community who have encountered bogus charges on their medicare statements as well. Most all and any agencies funded by tax payer dollars are in desperate need of major accountability and regulation oversight. This is a fact because we have seen the reality of so-called self-regulation. We are a capitalist society whose very nature is based on greed, not equity. Consider the blatant expose in American Samoa.
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by debusehma October 29, 2009 8:24 AM EDT
We did not watch 60 Minutes as we don't watch much TV...too biased. I ran across this story while doing some surfing for a medical problem. Enjoyed the many informative comments posted here. The time is ripe in the U.S. for a real "across the board change". Maybe a "Common Sense Integrity Party"? You betcha! I know, I know. A third party wouldn't stand a snow balls chance in hell of surviving the wrath of the D.C. power brokers.
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by BIGBEAR1947 October 28, 2009 10:00 PM EDT
Now that our blood is boiling, how about one on Social Security/Medicare? There are hundreds, maybe even thousands of innocent disabled Americans victimized by the stupidity of their own government run system. No wonder Medicare is so ripe for fraud. One quick case in point. I am the father of a disabled 35 year old injured at 18 in an automobile accident. While attending college she worked a part time job and received a small disability check. After college her part time job became full time and she reported each year that she was now full time but the checks kept coming and she was even given increases and end of the year cost of living bonus checks and told she was suppose to get them, she deserved them. She was convinced by Social Security/Medicare that she was suppose to have this money. It took eight years for them to find out they were doing this and contacted her demanding $80K back. Since this happened we have learned this has been the norm in so many other cases. Most of the disabled are riddled with expensive medicine, wheelchairs, supplies, etc. and become victims again of a very poorly run program designed to help, not victimized these people again. If CBS wants another good story on Social Security/Medicare I have plenty to offer. Please contact me.
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