"There was a famous case here in Dallas where a Nigerian woman had been busted," Burgess says. "As she was going off to jail, it was discovered that she had several other provider numbers. They discovered that she was receiving checks at the same post office box. It never occurred to anyone that, 'Hey anything that goes to P.O. Box 9058, that's a red flag.' We were probably paying for her defense."

This slack oversight allows for glaring aberrations. In one instance, Texas's Medicaid dental program spent more on braces than the rest of the country's programs combined. But CMS only learned of it when TV reporter Byron Harris broke the story in Dallas.

Even more shocking is the case of New York state. Its centers for people with mental issues were charging the feds $5,000 per day per patient. Arizona, by comparison, charges $200 a day.

David Feinwachs found that HMOs in Minnesota had turned Medicaid into a cash cow, making it several times more profitable than their private insurance.
Courtesy David Feinwachs
David Feinwachs found that HMOs in Minnesota had turned Medicaid into a cash cow, making it several times more profitable than their private insurance.
Texas U.S. Rep. Sheila Jackson Lee carried water for Medicare swindler Riverside General Hospital.
David Ortez
Texas U.S. Rep. Sheila Jackson Lee carried water for Medicare swindler Riverside General Hospital.

The reimbursements were based on a changing formula that CMS kept approving even as payments skyrocketed. New York's estimated overcharges: $15 billion.

This time, CMS discovered the state's gouging on its own. But six years later, it's still negotiating a remedy. CMS now plans to let New York phase out its overbilling, essentially allowing the state to steal a little less each month. (CMS officials declined to be interviewed for this story.)

More obvious improvements still elude the agency — even such basics as changing a beneficiary's Medicare number when theirs is stolen or used in a fraud. Others wonder why CMS hasn't mimicked the credit-card companies, which flag suspicious behavior within minutes.

"I sent my staffer to Chick-Fil-A with my personal credit card to charge $100 of sandwiches for our office for lunch," says Burgess. "So I'm called off the floor of the House to answer a phone call from my credit-card company saying, 'Hey, someone is trying to charge $100 worth of sandwiches.' Why can't they do that?"

Obamacare has allocated $100 million to CMS to create a similar system, employing data analytics to mine for suspicious claims. The new proactive stance includes a spiffy command center in Baltimore linked to field agents. In its first full year, the system identified or prevented $115 million in fraud.

But as Burgess notes, Obamacare provided CMS with "seven new tools" to fight fraud. Four years after the law passed, CMS has managed to enact just one.

"At this rate, some point before my natural death, maybe we'll have done half of them," says the congressman.

Though most everyone agrees that the government is moving in the right direction, $100 billion continues to walk out the door each year.

"This is a lucrative business, and business is good," says Feinwachs. "The only problem is that you and I are funding it."

« Previous Page
 |
 
1
 
2
 
3
 
4
 
5
 
6
 
All
 
My Voice Nation Help
2 comments
Juan_Leg
Juan_Leg topcommenter

It's nearly destroyed 'Pain Management' in Colorado . The absolute WORST culprit in this entire health care melt down was of course Dr. Clemmons, and the damage he has done is NEARLY irreversible !

I'm an amputee who has survived being run over by a train as well as hit by a car twice . I keep ALL my records/tests up to date, but CAN'T find a Doc who specializes in pain, & trusts ANYONE ! I was NEVER one of Clemmons' patients & did NOT play games w/ my pills EVER ! Nor was I EVER accused or investigated !

I'm SO close to quitting what little I do get now & returning to on going binge drinking . This coming after quitting drinking YEARS ago ! 

I AM BEING FORCED TO SELF MEDICATE W/ ALCOHOL !!!

 
Loading...