Oklahoma senior citizens are being urged to recognize and report — without fear of recrimination — suspected cases of Medicare fraud and abuse.
“All of us end up paying for fraud,” said Sanford C. Coats, U.S. attorney for the Western District of Oklahoma.
“It takes critical resources out of our health care system and drives up the cost. This adversely affects the Medicare program upon which millions of Americans depend.”
Some 1.1 million Oklahomans 65 or older or disabled receive $3.9 billion in Medicare medical services annually.
In the United States, Medicare benefits are projected to reach $550 billion this year, providing health insurance to more than 48 million Americans.
Fraud on the rise
In the past three years, the number of criminal and civil cases involving Medicare fraud in Oklahoma has increased by 350 percent, according to the U.S. Department of Health and Human Services Office of Inspector General.
There have been seven criminal prosecutions and 38 civil settlements, with more are expected in the future. Federal officials report collecting settlements of $22.4 million.
Cases involve bogus companies, scheming individuals and medical practitioners who overcharge Medicare for prescription drugs, bill for services or medical equipment never received, and commit other unlawful health-care practices.
Nationally in 2010, federal authorities opened 1,116 new criminal health care fraud investigations. In addition, they filed charges against 931 defendants, secured 726 criminal convictions, opened 942 new civil health care fraud investigations, excluded 3,340 individuals and entities from participating in the Medicare and Medicaid programs, and recovered more than $4 billion.
“Most health care providers are honest and ethical,” said Coats. “Unfortunately, there are a few who choose to engage in billing fraud and abuse.”
Fraud is committed by physicians, clinics, hospitals, medical-device providers, pharmaceutical suppliers, and other health-care professionals. Also, nonmedical individuals create fraudulent companies to bill for services or equipment, or commit medical identity theft in order to receive medical benefits, buy drugs, or submit fake billings, Coats said.
State seniors are encouraged to be watchdogs and whistle-blowers.
Seniors are advised to meticulously read their Medicare summary notices and their bills from hospitals or health care providers, even if the cost already has been paid by Medicare and the paperwork isn't asking the patient for money out-of-pocket.
“I do frequently urge seniors to check over their medical reports carefully,” said John Terneus, a member of the state Council on Aging from Yukon. “While one patient's error may be small — $10 for an aspirin — the same error for 1,000 patients adds up.”
When senior citizens see something that doesn't make sense on their medical statements, they should contact the Medicare Fraud Hot Line.
“Day-to-day providers can make simple errors that result in waste, but sometimes those improper billings are intentional,” said Ray Walker, director of the Senior Health Insurance Counseling Program for the Oklahoma Insurance Department.
“Patients should read their statements closely, looking for that wheelchair they didn't need or that procedure or treatment that never occurred.”
Identity theft warning
Foreign scams comprise part of the annual Medicare fraud, officials said.
Callers might tell potential victims that they need a ‘new' Medicare card, or that Medicare benefits now are being connected to the patient's bank account. “What they're really after is your bank information,” said Walker “Their stories can be very creative.”
James Crowder, a State Council on Aging member from Oklahoma City, places some of the blame for Medicare fraud squarely on how the health-care program is operated.
“I think that if Medicare payments were not so automatic, much money could be saved,” he said. “The source of any claim that is new should be checked out before money is spent. Apparently every claim is thought to be legal and honest without any investigation.
Some local Medicare fraud cases, include:
• An orthopedic surgery group headed by microsurgeon Dr. Houshang Seradge in Oklahoma City paid $3.5 million to the U.S. government to settle Medicare fraud claims. Federal prosecutors said defendants knowingly submitted false claims for payment to Medicare, Tricare's military health benefits, and the Federal Employees Health Benefits. It was alleged defendants submitted charges for medical procedures not performed. Defendants denied liability.
• In Alva, family physician Gregory Pinegar was charged with overbilling Medicare for two prescription drugs: Procrit for cancer patients, and Remicade to treat rheumatoid arthritis. He falsified information in his patients' medical records and caused staff members to send false billing information. For defrauding Medicare, Pinegar was ordered to pay $474,000 in restitution and a $1.5 civil fraud consent judgment. He spent time in a Texas prison and permanently surrendered his state medical license.
• In the Oklahoma City area, a case is pending against two individuals who opened First Century Medical Supply, purportedly providing power wheelchairs and accessories to Medicare beneficiaries. The government alleges the pair illegally pocketed $300,000 from Medicare for power wheelchairs which beneficiaries either didn't receive, received a less-expensive motorized scooter, or received a wheelchair neither requested nor needed.
• Another pending case charges a Tecumseh man who operated Heartland Orthotic Prosthetic Lab with fraudulently obtaining $5 million from Medicare and $600,000 from Medicaid by selling expensive, computerized prosthetic limbs, when the beneficiaries actually received less sophisticated prosthetics or none at all.
Killackey is a member of the Oklahoma Council on Aging.