Fraud with assistance of disinterest

Sa­lomon E. Mel­gen, of North Palm Beach, Fla., was charged with 46 counts of health-care fraud for, among other things, al­legedly sub­mit­ting false claims to Medicare be­tween 2004 and 2013, re­ceiv­ing $105 mil­lion in pay­ments over six of those years from the fed­eral pro­gram for the el­derly and dis­abled…
The in­dict­ment de­tails more than two dozen pa­tients for whom Dr. Mel­gen allegedly sub­mit­ted fraud­u­lent billing to the tax­payer-funded pro­gram…
In one case, Dr. Mel­gen fraudu­lently billed Medicare about $385,000 from 2011 to 2013 for tests and pro­ce­dures on both eyes of a man, ac­cord­ing to the in­dict­ment, in­clud­ing some 70 in­jec­tions of the costly eye drug Lu­cen­tis, used to treat mac­u­lar de­gen­er­a­tion, the in-dict­ment claims…  Excerpts from WSJ article 4-16-15

This is the guy involved with New Jersey’s Senator Menendez. Appears to be quite a greedy character doesn’t he?

Getting away with this level of fraud is just another symptom of the problem the Medicare bureaucracy has with claims management; a long-standing and well documented problem. However, there is another factor in all this, the Medicare beneficiary.

You may recall if you have ever filed a health insurance claim that eventually you also receive an Explanation of Benefits (EOB). That form provides information on the date of service, the provider, type of service, fee charged and allowed and the payment. 

Wouldn’t you think that over nine years, two dozen patients and $105 million someone would have said, “Hey, I never received those services!”