Medicare self-fraud

[samclem]

There was an electric wheelchair in the house we bought (left behind with dumpsters worth of other stuff--that's another story). It was not a modern one, but worked and had all the accessories. Goodwill wouldn't accept it as a donation due to liability issues.

Liability laws (and their application) need reforming.

 

[Martha]

Please note that fraud is not limited to Medicare fraud.

Anti-Fraud Resource Center
The National Health Care Anti-Fraud Association (NHCAA) estimates conservatively that 3% of all health care spending—or $68 billion—is lost to health care fraud. That’s more than the gross domestic product of 120 different countries, including Iceland, Ecuador, and Kenya.[1]
Other estimates by government and law enforcement agencies[2] place the loss due to health care fraud as high as 10 percent of our nation’s annual health care expenditure—or a staggering $226 billion—each year. And the cost of health care will only continue to rise[3], which means the price tag associated with health care fraud will rise too unless we can work together to combat it.



Here is an interesting fraud problem: medical identity theft:

But are you as familiar with the risks posed by medical identity theft? You should be, considering that 250,000 to 500,000 individuals have been victims of this escalating crime[4]. When a person’s name or other identifying information is used without that person’s knowledge or consent to obtain medical services or goods, or to submit false insurance claims for payment, that’s medical identity theft. Medical identity theft frequently results in erroneous information being added to a person’s medical record, or even the creation of an entirely fictitious medical record in the victim’s name.
Victims of medical identity theft may receive the wrong medical treatment, find that their health insurance benefits have been exhausted, and could become uninsurable for both life and health insurance coverage.

 

[ERD50]

Please note that fraud is not limited to Medicare fraud.

Well, I certainly don't expect any system to be free of fraud, cheats will try their hand wherever they see a chance. So if that is the requirement, we might as well just stop with any changes now. Although, I'm not sure that was your point?

My point is that a voucher system would seem to provide a motivation to reduce waste in the system. Consumers would be motivated to shop for the best deals. Suppliers would be motivated to attract customers with better services and prices. Or at least more so than today. I think it would be an improvement (if properly structured).

In a "the govt is going to pay for it" system - where is the motivation to reduce waste? Clearly, in these wheelchair stories, there is none. If you look at some of those ads, it's all "come to the trough and get yours - it's freee!!!"

-ERD50

 

[samclem]

Just to be precise, I don't think there's anything fraudulent about the wheelchair renting situation in Medicare as it has been described. It is clearly wasteful and it might be an abuse of the system.

I am sure that waste is a much bigger problem in the Medicare system than is fraud. And, the best way to combat waste is to give the patient a vested interest in reducing costs (e.g through a cost-sharing co-pay system) and to assure the insuring entity (public or private) has a motive to reduce wasteful internal practices and external expenditures. With private insurers, this motive is the profit motive. With government insurers, the motivation to reduce costs is . .. I'll have to get back to you on that one.

 

[FinallyRetired]

Just to be precise, I don't think there's anything fraudulent about the wheelchair renting situation in Medicare as it has been described. It is clearly wasteful and it might be an abuse of the system.

Exactly. That's why I called this a self-fraud case. Because if you or I billed Medicare thousands for services or equipment worth $250 at most we'd be charged with fraud. But they're happy doing it to themselves, which is why I accused the lady on the line of self-fraud.

Technically, this is a case of waste. But it's such an outrageus case, that I'm inclined to put it in the category of fraud. At the beginning, someone somewhere defrauded Medicare by allowing such a practice, and it's been perpetuated ever since.

 

[Brat]

Medicare clerk you spoke to had no authority to change the regulations. She gave you the information you need to change them. I think the time is ripe to do that.

 

[ERD50]

Translation Please:

Medicare FAQ | Medicare Wheelchair | Medicare Lift Chair | Medicare Hospital Bed | Medicare Walker | Medicare Rollator | File Medicare Claim

Q What does capped rental mean?

A For the majority of products covered by Medicare, 80% of the rental is covered for 13 continuous months of use. Most secondary insurers pick up the remaining 20%. Products covered as capped rental of 13 months:

• Hospital Beds.
• Manual Wheelchairs.
• Patient Lifts.
• Some Support Surfaces such as Low-Air-Loss and Alternating Pressure mattress.

After Medicare has paid for 13 months of continuous use, the supplier may transfer the title to the beneficiary.

So does this mean that someone w/o supplementary insurance would be paying 20% of that $237 each month? 13 months times $237 * 20% = $616 (out-of-pocket) for a $90~$140 wheelchair?

TIA -ERD50

 

[FinallyRetired]

Medicare FAQ | Medicare Wheelchair | Medicare Lift Chair | Medicare Hospital Bed | Medicare Walker | Medicare Rollator | File Medicare Claim

So does this mean that someone w/o supplementary insurance would be paying 20% of that $237 each month? 13 months times $237 * 20% = $616 (out-of-pocket) for a $90~$140 wheelchair?

TIA -ERD50

Good find. I went back to the medicare receipts and, sure enough, medicare "only" covered 80%. The other 20% was payed by Tricare. So Medicare pays $2464.80 and Tricare pays $616.12 for a $250 list price wheelchair.

If someone has no secondary carrier, they could pay the $616, or just buy the darned thing for maybe $90. Of course, if they buy it they give up the chance for that $10,000 motorized wheelchair in the future.

 

[ERD50]

If someone has no secondary carrier, they could pay the $616, or just buy the darned thing for maybe $90.

And most likely, the very people who do not have secondary insurance are the ones who need to control costs the most. Further, those same people are probably less likely to be doing comparison shopping on the internet and so forth. They probably just "trust" that the 20%/month payment is a good deal ("I'm only paying 20%, Good Old Uncle Sam is picking up the rest!").

So, how many needy people have paid $616 out of pocket for a $90-$140 wheelchair? What a shame. Yet, it is the Capitalists that are so often criticized for not having a heart. I don't get it. Who's the good guy here, and who's the bad guy

No wonder that sarcastic line "I'm from the Government, and I'm here to help you! ", has endured.

Yep, we need more of this kind of help

-ERD50

 

[harley]

No wonder that sarcastic line "I'm from the Government, and I'm here to help you! ", has endured.

I guess you couldn't find the smiley pointing a gun at you.

 

[ERD50]

I guess you couldn't find the smiley pointing a gun at you.

heh, heh, heh - that one will work too!

and here comes a man, with paper and a pen,

telling us our hard times are about to end.... The Band

-ERD50

 

[samclem]

This would make an interesting case study-- I wonder how much Medicare pays, on average, to rent wheelchairs for patients who have no supplemental coverage compared to those people with the coverage. I'll bet that if Granny is writing a check for $47 every month, that it only takes a few months for her to spot the scam and put a stop to it.

 

[free4now]

Hospitals routinely charge $7 for a single tylenol tablet (more than a bottle of 100 anywhere else), and private healthcare providers routinely pay it. The cost of administering the tablet is extra. Single payer isn't the problem.

I favor some sort of universal HSA type catastrophic health insurance for everyone in the US, where the first few thousand per year comes from the insured. That will keep this waste from getting out of control; people will just bring a bottle of tylenol from home and mail order their wheelchairs.

 

[ERD50]

Hospitals routinely charge $7 for a single tylenol tablet (more than a bottle of 100 anywhere else), and private healthcare providers routinely pay it. The cost of administering the tablet is extra. Single payer isn't the problem.

There is a flaw in your logic. Just because there is a problem with X, that does not mean Y is better or worse or the same. Gotta dig a little deeper.

But you raise a good point. Why is it that private ins cos seem to routinely pay what appear to be outrageous charges?

Dental is simpler for me to think about, it's generally more routine and more limited in scope and common. Offhand, none of the charges from my dentist seem too out of line. It takes skill and time to fit a crown and there are liabilities if you do something wrong; him and his staff needs to charge a fair price. And when DD went in for wisdom tooth extraction, the office offered the whole set of meds to me for $20 (pain killers, prednisone, antibiotics) - that was worth it to avoid a trip and waiting at the pharmacy, and I may have paid more there, I don't know.

Medical, tougher call. My other DD had some tests recently that were very expensive ($ thousands each for ~15 minute run on several different instruments), and the equipment looked like it probably earned it's cost back in 1992. Obviously, the specialist who interprets the data can earn good money for his skill, but those are separate charges. BTW, the tests confirmed no real problem just a suspicious symptom that needed to be checked, so that story ended well, just drained my pocket book a bit more than I think it should have.

-ERD50

 

[Brat]

My Mother was in a nursing home for years. They forbid a resident consuming meds obtained from anyone but their institutional pharmacy, even over the counter ones. When she was dying she needed pain med on a Sunday which could be obtained at the pharmacy a few blocks away (which we could give her) but we were required to wait for the institutional pharmacy to deliver 6 hours later. They said it was state law.

 

[harley]

My Mother was in a nursing home for years. They forbid a resident consuming meds obtained from anyone but their institutional pharmacy, even over the counter ones. When she was dying she needed pain med on a Sunday which could be obtained at the pharmacy a few blocks away (which we could give her) but we were required to wait for the institutional pharmacy to deliver 6 hours later. They said it was state law.

"It's easier to ask forgiveness than it is to receive permission" - Amazing Grace Hopper

 

[Darryl]

I favor some sort of universal HSA type catastrophic health insurance for everyone in the US, where the first few thousand per year comes from the insured. That will keep this waste from getting out of control; people will just bring a bottle of tylenol from home and mail order their wheelchairs.

I've had a HDHP with HSA for a couple of years now and I've accumulated about $5000 that would have been paid out in just premiums so I'm pleased I've accumulated some money.
More notably I've also noticed how it's changed my behavior when I'm buying healthcare. On many occasions when I would have sought service under my old HMO I''ve delayed service started feeling better and never needed an office visit. I've also had issues that were concerning to me but may not have been approved for payment by my HMO as medically necessary. When I saw my provider hesitating to order tests I said hey this is a concern I've got and nobody will fight this because I'm the guy paying, and they've written the order. I don't believe I would have received those tests if it was up to the insurance Co... Thankfully those tests came back in my favor and one could argue they should have never been done, at the same time concerns I've had for 5+ years were put to rest so I was happy to pay for that.
I read every bill, I work to push tests that were every three months to four months so they recur 3 times per year not 4. I am an active participant in my healthcare and I would buy the darn wheelchair mentioned in previous posts.
We do have a mess with our current system I sure hope the fix unlinks employment and keeps the individual involved in their care.