

How Medicare Became a Thieves' Bazaar - lgv
http://www.dallasobserver.com/2013-04-25/news/how-medicare-became-a-thieves-bazaar/

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WalterBright
There's also the issue of crafting a business model around the rules on how
Medicare pays out. This is not fraud, as it follows the letter of the law, but
it's an enormous cost.

For example, ever notice those TV ads where you can get some equipment, like a
scooter, "at no cost to you"? That's a business based entirely around looking
for people they can get qualified for free stuff from Medicare, then they make
money by billing Medicare.

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guelo
Actually, the article mentions that that scooter company got busted for fraud.

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WalterBright
I saw another one just yesterday on TV for another device "at no cost to you".

"Frontline" also had an episode investigating dental clinics that have
sprouted up that were specifically designed to extract max dollars from
government programs to get dental services to poor people.

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ChuckMcM
Reminding me once again that there still exists problems for which Congress
could apply itself and get credit for "healthcare reform" from both sides of
the aisle.

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niggler
What are the actual figures regarding Medicare fraud? I've seen conservative
groups quote numbers like $.20-$.50 of each medicare dollar while liberal
groups quote numbers like $.01-$.05

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jseliger
One issue is that the line between "fraud" and "creatively working around
rules to make sure the doors stay open" is thin and porous.

I'm part of a grant writing consulting firm, and we've worked for many
Community Health Centers (CHCs, also known as "Section 330 providers"). Most
rely on some combination of Medicare / Medicaid funding, donations, and grants
to keep their doors open. Medicare and Medicaid reimbursement rates are
basically too low to pay for some combination of doctors, PAs, and NPs to
provide care. Consequently, some combination of things happen:

* Care is so awful that it doesn't effectively exist. A patient sees a provider for one to two minutes and then gets hustled out the door with their problems put off until the next visit, since CHCs can bill by the visit, not by the time spent.

* Care is somewhat better but creatively accounted for. What if someone sees a provider for two, fifteen minute visits instead of one half hour visit?

* Some number of phantom patients receive services.

You may now call out that number three is FRAUD and THEFT and STEALING. But
the virtuous organizations that _don't_ use some form of creative accounting
can't exist because they can't pay the rent, for supplies, and for providers.
So there are game-theory-style incentives built in for working the system in
such a way that the organization can survive. The feds know this, which is why
they offer programs like the New Access Points (NAP), to throw a bone to CHCs
(see here: [http://blog.seliger.com/2010/08/11/the-health-resources-
and-...](http://blog.seliger.com/2010/08/11/the-health-resources-and-services-
administration-hrsa-finally-issues-new-access-points-nap-
foa-250000000-and-350-grants-plus-some-important-history/) for one place we've
written about it).

Given this, what counts as "fraud?" The answer is, "It depends."

(A tangential note: we've worked for CHC clients in MSAs with a million or
more people who are the only PCPs that accept Medicare / Medicaid.
Specialists? Forget about it.)

