Some of America’s biggest companies are issuing millions of dollars of payments to Medicare patients with questionable or nonexistent medical claims, according to a new survey conducted by Nationwide Mutual Insurance Group.
Under federal law, insurers are required to investigate potential fraud that affects their beneficiaries. So Nationwide collected data from the companies in which it insures 5.4 million Medicare beneficiaries, which at $4.2 billion in 2017 was third-largest provider of Medicare benefits in the country.
“The goal was to see if they paid the highest dollar amount into providers for providers they have a lower-than-average claim frequency with,” said Jim Hart, senior vice president for Government Affairs at Nationwide.
Nationwide discovered the extra payments from New York, Illinois, Florida, Kentucky, North Carolina, Tennessee and Washington, D.C. each averaged $50,000 a year, or more than 50 percent more than the $30,000 national average.
“These claims — most of which had little evidence to support the claim — were at risk of fraudulent activity,” Hart said.
Unethical or unscrupulous doctors who submitted fake claims for health care usually find an interested party to pay their bills to give the appearance that they were properly billed.
A felony scheme started when a doctor was embezzling a private practice in Florida. Instead of finding an honest buyer, the doctor turned to the Medicare Program Management office, which only reviews some claims, and submitted an extra claim on a patient’s behalf. The payments were hidden by mail and buried in other official-looking files. The scheme began in March 2017 and reached $12 million in February 2018, but the fraud was only discovered after another doctor filed a complaint.
“There’s a $50,000 difference in payment between one doctor, trying to divert money from Medicare, and another doctor trying to obtain higher payments from Medicare,” Hart said.
Nationwide discovered the fraud a year ago and reported it to the federal government. The average cost of the scam was a lower amount, $23,000, partly because the extra payment covered less of the care.
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Bold, beautiful: Chinese calligraphy revealed in 20th-century works The total cost to the taxpayers in these five cases was $70,000, and Nationwide expects to recover about $10,000 of that through legal action.
Nationwide now advises its brokers to slow down payments to doctors or hospitals who submit questionable or nonexistent claims to Medicare.
“How the doctors behave is a sign of future fraudulent activity in their relationship,” Hart said.