Here is what “low administrative costs” and a claim policy that is pay and pursue get you. $1 billion in fraud not caught for fourteen years. If Medicare followed procedures common with private insurance companies, this would be very unlikely.
Patients and doctors hate pre-authorization and medical necessity scrutiny and it can be annoying, but this case is just one of way too many examples of what happens when you have a loose claim policy. Government oversight groups have been pointing this out for years and yet little has been done.
The New York Times
7-22-16
U.S. Says Florida Network Defrauded Medicare and Medicaid of Over $1 Billion
By ERIC LICHTBLAU
JULY 22, 2016
WASHINGTON — In the largest case of health care fraud ever brought by the Justice Department, federal prosecutors on Friday charged three people at a network of Florida nursing and assisted-living facilities for their suspected role in a scheme to defraud Medicare and Medicaid of more than $1 billion.
Prosecutors charged that Philip Esformes, 47, of Miami, who owns 30 nursing homes and assisted-living facilities in the area, created a fraudulent network built on billing Medicare for performing lucrative procedures that were not needed.
Over a period of 14 years, Mr. Esformes’s facilities would take in Medicare and Medicaid recipients who did not actually qualify for skilled nursing or assisted-living facilities, then bill the government programs for their care, prosecutors charged.
QUINNSCOMMENTARY 
One comment