This editorial will appear in tomorrow’s print edition.
Forget drug trafficking. For criminal enterprises, the real money is in Medicare.
A case in Texas demonstrates how much loot can be gotten by illegally tapping the immense federal health insurance for seniors. U.S. prosecutors on Tuesday charged a doctor, Jacques Roy, with masterminding a conspiracy that fraudulently billed $350 million to Medicare over the last five years, plus another $24 million to Medicaid.
One doctor. A third of a billion dollars.
He did have help, according to the U.S. Justice Department. Investigators say that Roy’s business, Medistat Group Associates, worked with home health care agencies to recruit thousands of Medicare-eligible patients. The patients would be given unnecessary medical services and home visits at Medicare’s expense, say the investigators.
The owner of one home care agency reportedly paid recruiters $50 a head for “patients” they found at a homeless shelter.
The Obama administration has been trumpeting these Medicare busts as evidence of its success in rooting out the fraud and abuse that may be filching as much as $60 billion a year out of the approximately $500 billion the country spends on the program every year.
Last year, the feds say they recovered more than $4 billion of stolen Medicare money. The administration has greatly stepped up enforcement in the last two years, creating a well-funded Medicare Fraud Strike Force and – more recently – a computer system designed to track billings and flag suspicious patterns.
Roy’s enterprise, for example, hit the radar screen when data analysis showed that he had certified more than 5,000 home health patients in 2010. According to the Department of Health and Human Service, 99 percent of doctors certify, at most, about 100 patients.
Medicare fraud takes many forms.
Doctors may bill for services they didn’t provide, or “upcode” a less expensive procedure to a more expensive one. Patients who’ve had their personal information stolen find that the government has been billed in their names by providers they never met for expensive medical equipment they never saw. In some cases, patients are co-conspirators who get kickbacks out of the deal.
South Florida has become notorious for phantom pharmacies that bill Medicare for hundreds of thousands of dollars worth of fictitious drugs and equipment – then quickly close before auditors get wise.
The crackdown is welcome and necessary. Roughly 47 million Americans are now enrolled in Medicare, and the retirement of baby boomers is expected to swell that number to 80 million by 2030.
The nation will be burdened enough paying for their health care; it can’t afford to pay untold billions more to criminals who siphon fortunes out of this river of federal money.