Medicare Fraud Policies & Procedures
Medicare fraud is rampant within the health care system. Some unethical physicians and facilities have been exploiting a hole within Medicare, which allows them to bill the program---and ultimate, taxpayers---for services that were never rendered to patients. The fraudulent billing does more than damage the program and take money away from those who truly need the coverage. In fact, if a physician uses your name and coverage for making fraudulent charges, it can severely impact your ability to have your medical care covered by Medicare.
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History of Medicare
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Medicare is a health insurance program paid for by American citizens' taxes. It is socialized welfare that provides coverage for individuals who are 65 years or older, and have paid into the Medicare program for at least 10 years before applying. It was created in 1965, with the last major changes to the program taking place in 2006.
How Medicare Fraud Works
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Medicare's billing system is vastly different from typical private health insurance. For starters, Medicare pays the full costs of whatever a physician charges for care, something virtually unheard of in the private insurance sector. This practice not only increases the program's and ultimately, the taxpayers' costs, but entices physicians to file fraudulent claims in return for higher reimbursement.
Medicare also has no system in place to check the claims physicians file. Unlike traditional health insurance, patients do not receive a bill for services in the mail -- everything is handled directly by the physician and Medicare. This means patients can't alert Medicare if a physician or facility charges for services they never received. In addition, Medicare audits an estimated 2 percent of all filed claims, which means fraudulent claims are easily passed through the system without ever being caught.
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How Medicare Fraud Affects You
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Medicare fraud affects everyone indirectly, either by taking critical money away from the program and leaving less for participants, or by costing you more in taxes to cover the gaps. It also directly affects the patients that physicians file fraudulent claims on behalf of. This can take money directly out of your pocket through copays for services you never received, and if the physician files expensive claims or too many claims, it can also max out your benefits for the year. This leaves you with no coverage through the program when you legitimately need treatment.
Procedures to Report Medicare Fraud
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If you suspect Medicare fraud is happening,in your name or someone else's, you can report your suspicions to the office by phone or online. You can find the number to contact Medicare on your membership card, or visit Medicare's website directly. The physician will not know you were the one who made the report.
Procedures to Prevent Medicare Fraud
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To date, there are only two ways to catch Medicare fraud: through audits and through individual reports. Many physicians have learned how to cover their fake claims, and auditing rarely ever exposes most of them. The other way is through patient reports, which have previously helped to exposure quite a few large cases of repeated fraud.
Penalties for Committing Fraud
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Physicians who commit Medicare fraud can receive fines of up to $10,000 for each incident, have their license suspended or permanently revoked, and receive prison sentences, depending on the amount of money they fraudulently obtain from Medicare and how long they defrauded the program for. Facilities can also be fined and shut down for participating in Medicare fraud.
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