Medicare Fraud Strike Force Targets 'Bad Actors' In The Dallas Area | KERA News

Medicare Fraud Strike Force Targets 'Bad Actors' In The Dallas Area

Sep 17, 2018

The Justice Department in June announced charges against more than 600 people responsible for more than $2 billion in health care fraud losses over a 12-month period.

That stems in part from 10 strike forces across the country created to investigate Medicare fraud. The Dallas unit began in 2011.

C.J. Porter, the special agent in charge of investigations for the U.S. Department of Health and Human Services Office of Inspector General’s Dallas Region, said the numbers clearly identified the need for a strike force.

"Data analytics identified Dallas as a hot spot where home health services was an issue," Porter said. "And our reimbursement rates and the number of businesses in this area were higher than what the national averages were."

The strike force's work to date has led to 70 convictions and more than $355 million returned to the program. But Porter says the public can help by reporting suspicious behavior, starting with information you get from your insurance company.

"The patient population can be the gatekeeper as well by reviewing the explanation of benefits," she said. "When they see a physician name they don’t recognize, those types of individual instances are extremely helpful."

Interview Highlights

Why home health care’s subject to fraud: Medicare is a trust-based system and so there’s always going to be some bad actors in a program like that. But, second, I believe there’s been a campaign of misinformation to our patient population.

Typical is you go to your primary care physician or you go to a specialist your primary care physician has referred you to, and that person helps determine what your medical needs are, what appointments you should have, what tests you should have, and if you do need home health services.

What has happened is a reverse engineering of that process. These companies come out and go door to door and they recruit patients, and they bring a doctor who has maybe had no contact with this patient before, and now this person is selling their signature to let these companies build these programs and it result these millions of dollars in fraud.

How fraud victims are chosen: If you have a Medicare number, you are at risk of being recruited into one of those schemes. That’s really all that’s necessary for a bad actor in the program to bill for you. What happens is our community’s relatively trusting.

So, if you attended a church function and someone has come up and introduced themselves to your pastor and tells a group of people that just because you have Medicare, you’re eligible for all these programs. That group of people hasn’t had that education before and they will believe that.

The physician should be the person that’s introducing those available programs to you when you have a medical need for them. If it comes from another direction on a regular basis, that should be a red flag.

What about federal oversight: We have 70 convictions and we’ve gotten over $355 million returned to the program. But the doctors are supposed to the gatekeepers of the program. And when a physician is a bad actor, and they’re willing to make decisions based on financial gain rather than someone’s medical needs, the results of that are very damaging.

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