HEALTH CARE/Joan Retsinas

Reducing Health Care Fraud: Beyond Eliott Ness

Think Medicare. Now think fraud. Google has 4,210,000 sites for “Medicare fraud,” 3,170,00 for “Medicaid fraud”. We’ve marshaled Eliot Ness-type teams to hunt it: earlier this year, a national Fraud Strike Force, comprising 700 personnel, hailing from the FBI, the Department of Health and Human Services’ Inspector General, state attorneys general, and state and local police, issued indictments against 111 individuals for stealing $225 million.

The Strike Force targeted 9 cities, including Los Angeles, New York, Dallas and Chicago. They used the tools familiar to Law and Order aficionados: search warrants, forensic audits, retrieval of computer records. Last year Medicare’s fraud-busters recovered $4 billion. The Secretary of HHS estimates that every dollar spent rooting out fraud yields $6.80.

The sobering statistic, though, is the actual extent of fraud, because the figures that end up in the news – the indictment headlines – undercount the crime. Typically, strike forces go after the big perps. They rarely trail the mom-and-pops. Nor do they pursue every questionable claim that might not survive litigation. It isn’t worth the manpower.

A dismaying number of providers are scamming Medicare and Medicaid.

The scams are drearily familiar. Clinicians bill for services never provided, for more services than provided, or for more complex services than provided. Cagey perps will steal identities from patients; “patient recruiters,” lured by kickbacks, gather names and Medicare ID numbers for the artful dodgers. Some patients receive payment, but some don’t know that their clinicians are ripping Medicare off. A patient gets home care for three weeks, not the six weeks billed. Another patient is billed for an elaborate wheelchair, but receives a basic one. Medicare pays for drugs, orthopedic shoes, oxygen that patients don’t need, don’t receive. Generally patients do not suffer: these perps are not operating on wrong body parts. But the crimes are not victimless: the victim is the government-run health insurer and, consequently, the taxpayers.

The perps are physicians, nurses, occupational and physical therapists, pharmacists, health care executives. Without resorting to fraud, they could earn respectable salaries. Indeed, these are solid fields: a physician, therapist, or nurse can readily find non-felonious employment. As for the executive-masterminds, they could be running legitimate health care organizations. The defendants evoke middle-class America, not a Sopranos’ rerun. The question looms: Why the scams, from people who could prosper without them? Greed plays a role: a fraudulent provider can triple a projected six-figure income. Yet many Americans manage on six-figure incomes. And many of these perps consider themselves respectable (the Sopranos’ minions never pretended to legitimacy).

Perhaps the fraud signals a deeper malaise: low government morale. James Surowiecki (New Yorker, July 11, 2011), in probing why so many Greek citizens don’t pay income taxes, traced the low compliance to the culture. He dubbed the phenomenon “low tax morale.” Citizens simply don’t see the government, and hence its strictures, as important enough to warrant compliance. Furthermore, non-payers are so rarely punished (the Greek courts have a backlog of 300,000 tax cases) that most citizens assess the risk of punishment as minimal – which reinforces the low morale. (Kenya wins a prize for lowest tax morale: the government opted to reimburse officials for paying delinquent taxes. Alphonce Shiunfi, Daily Nation (Kenya), Aug. 12, 2011 (nation.co.ke).

In the United States, a swathe of the electorate now proclaims government as harmful, inefficient, loathsome, or unnecessary (the adjective varies with the vitriol of the campaign).

As this swathe ascends, a mindset takes hold: the government payment rules are not important. So a provider, faced with the complicated forms, the changing regulations, the incessant memoranda from Medicare, may well think: who will know? Why not?

After all, I’m cheating a harmful, inefficient, loathsome, or unnecessary Uncle Sam. Nobody is likely to find out. And my patients won’t complain, even if they sense a billing disparity.

One solution for fraud lies with Eliot Ness strike forces. But another tack is to raise “government morale” for all of us, across the electoral spectrum. Fraud flourishes not solely in the hearts of larcenous fraudsters, but in the we-hate-government climate that gives people free rein to break the rules. Medicare is crucial to the health of millions of Americans; we must recognize it as such. And we must speak out when we suspect fraud. The Inspector General runs a hotline for citizens: 1-800-HHS-TIPS (1-800-447-8477), email HHSTips@oig.hhs.gov.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, November 1, 2011