Why it's so hard to prosecute health care fraud.
Perhaps the most chilling thing about Professor Terry Leap’s new book, “Phantom Billing, Fake Prescriptions and the High Cost of Medicine: Health Care Fraud and What to Do About It,” is the sheer number of different schemes people in the medical profession have come up with to steal money from insurance companies, patients, and the government.
The Crime Report or (TCR)
TCR: What is the most common kind of health care fraud?
Terry Leap (TL): I think the most common is billing Medicare for services that weren’t provided, or were unnecessary. Medicare is a huge target for health care thieves, simply because of its size. Over the next few years we’ll be approaching a trillion dollar budget. So there’s all this cash that people can steal, and of course there are so many claims, that if you don’t get too greedy you could just file claims that appear to be normal and no one really questions them.
TCR: Do we need new laws to help catch these people, or is the problem inadequate enforcement?
TL: I don’t think we need new laws. The problem is that law enforcement gives most white-collar crimes a lower priority. And I can understand why—they have limited resources. I had a county prosecutor tell me that ‘we settle our white-collar crime cases in civil court not in criminal court because we just don’t have the resources. We have to go after the people who murder, commit sexual assault, armed robberies and that sort of thing.
TCR: But with a billing scam, for example, it’s not that easy to detect. If I come home and my TV is gone, I know it’s been stolen. But if my doctor bills my insurance company for something I didn’t get, I might not even notice.
TL: Which is why I think that one thing that needs to be done is to educate consumers. Just looking at your insurance statement to see (whether) I really did get those services?―did I really get those medications?―can make a difference. The problem is you can’t read those explanations of medical benefits very well. I don’t always understand what the insurance pays and what it doesn’t pay. If they say you got a blood test and you know you didn’t get a blood test, okay…but if you were in surgery, how do you know? Did you get a transfusion? How much anesthesia did they use?
When my father passed away about a year and a half ago, my mother got bills from doctors and other healthcare providers she knew absolutely nothing about. I told her, don’t pay them, wait and see. Eventually they just went away.
Link:
http://www.thecrimereport.org/news/inside-criminal-justice/2011-06-throw-crooked-health-providers-in-prison