Medicare Compliance & Reimbursement

From cocaine to the Cogan Syndrome, many drug dealers in South Florida have been slowly but steadily switching over to Medicare fraud in the past three years. An article posted on www.npr.org says the FBI has interviewed those that have been arrested and, according to Malcolm Sparrow of Harvard's Kennedy School of Government, the primary reason they give is, "there's more money, there's much less chance of being caught and if I do get caught, I'll be treated like a white-collar criminal, not like a drug dealer."

And these former drug-dealers, along with other healthcare fraudsters in South Florida, have been preparing themselves all along for tougher times. More federal enforcement means that scammers are scrambling to devise schemes for siphoning off public money, a recent article in the South Florida Business Journal reveals. According to Cecilia Franco, director of the Centers for Medicare and Medicaid Services (CMS) Miami field office, the level of fraud in Miami-Dade county has gotten, "out of control," reports Brian Bandell with the South Florida Business Journal, in his post on www.bizjournals.com. Over the past three years, bogus companies by the hundreds, if not more, have shifted their fraudulent billing schemes from HIV/AIDS infusion therapy and durable medical equipment to home health, said Franco in the article.

To combat the problem, CMS, the Federal Bureau of Investigation (FBI) and the U.S. Attorney's Office for the Southern District of Florida have formed a healthcare fraud task force, reports Bandell.

"We can dedicate all 280 of our lawyers to prosecute healthcare fraud and it won't be enough," H. Sloman, acting U.S. attorney general for South Florida, told Business Journal. "Healthcare fraud is worse than the [Scott] Rothstein case ... and yet it isn't as demonized as much as it should be," he further said, referring to the Fort Lauderdale attorney who pleaded guilty to running a $1.2 billion Ponzi scheme.

What makes things all the more difficult is that these criminals adapt quickly to changing legal scenarios. For example, when task force inspectors discovered that nearly one third of durable medical equipment suppliers in the state didn't have legitimate places of work or business addresses, hundreds of new home health agencies sprouted all over Miami and medical billing shot up through the roof, according to Franco.

In many cases, beneficiaries allow fraudsters to use their billing numbers in exchange for kickbacks. This is because many beneficiaries are poor and these kickbacks outweigh by far their Social Security checks, said  Christopher B. Dennis, special agent in charge of the U.S. Department of Health and Human Services' Office of Inspector General in the Miami regional office, in the article.

Bandell also said that according to Franco most of these fraudsters use diabetic Medicare beneficiaries because such beneficiaries are "commodities" who can be used and reused many times. Beneficiaries, stated Franco, are switched over from medication they can take without assistance to insulin that requires a visit by a home health aide. That is when a Medicare beneficiary turns into a "commodity" in the fraudulent business, Franco said in the article.

(Editor's note: Read Brian Bandell's post at: www.bizjournals.com/southflorida/stories/2010/03/01/daily20.html. Read the Medicare Fraud article at: www.npr.org/templates/story/story.php?storyId=15178883.)