Guarding Your Medicare Dollars

It seems like it’s in the news regularly: a Medicare provider is being prosecuted for filing fraudulent claims for services never rendered or services for which they billed for a higher level of service than what was actually provided. These are a few of the many methods that are being used to bilk the Medicare Trust Fund.

Some of the common ruses are:

• ‘Overlapping Services’ – which means that a provider will bill as if they have given a service to a patient at one location when they have not.  An example of this scheme would be billing for an ambulance service when the patient is in an inpatient hospital stay.
• ‘Ping-Pong Beneficiaries’ – this scheme has providers move a beneficiary from one doctor to another doctor in an effort to maximize profit without benefiting the patient
• ‘Hit-And-Run’ – this is the practice of flooding the Medicare system with fraudulent claims and then moving quickly to avoid the consequences
• ‘Porpoising Providers’ – this is when doctors who have lost the ability to perform services in one area of the country resurface in another area with a different identification number
• ‘Balloon Effect’ – this is the practice of moving to a different pattern of billing once Medicare stops paying for a previously lucrative scheme

Some ways that Medicare searches for, and finds those perpetrating these schemes are through:

• Medicare contractor medical review – in which the contractor (such as Railroad Medicare) reviews claims for medical necessity and correct billing
• Railroad Medicare’s Benefit Integrity program – which proactively looks for suspicious billing patterns and investigates potential fraud and abuse identified through complaints or beneficiary contacts to our Provider and Beneficiary Customer Service Centers
• Zone Program Integrity Contractors (ZPIC) or Recovery Audit Contractors (RAC) – which perform similar functions to the Railroad Medicare’s Benefit Integrity unit

Other partners in the fight against these and other Medicare fraud schemes include:

• Office of Inspector General (OIG) – the largest inspector general’s office in the US Federal Government. Its mission is to protect Department of Health & Human Services (HHS) programs, such as Medicare 
• Health Care Fraud Prevention and Enforcement Action Team (HEAT) – a joint initiative between the OIG, HHS, and the Department of Justice (DOJ)
• Medicare Fraud Strike Force Teams —a key part of HEAT and operating in nine areas of the U.S. They use data analysis, as well as Federal, State, and local law enforcement entities, to investigate and prevent health care fraud and/or abuse

Since 2007, the Strike Force teams have:

• Initiated 1,938 criminal actions
• Won 2,498 indictments
• Collected more than $3 billion

To learn more about the activities of the Medicare Fraud Strike Force Teams, you may visit their website. 

As always, you may call our Beneficiary Contact Center at 800-833-4455, or for the hearing impaired, call TTY/TDD at 877-566-3572 to discuss your Medicare Part B coverage. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. until 7 p.m. ET. We encourage you to visit our Facebook page at www.Facebook.com/MyRRMedicare.