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Federal officials use new tool to track Medicare fraud

Florida has long been considered the leader in fraudulent Medicare billing. A Medicare fraud strike force used the results obtained in South Florida to launch a new computer system designed to identify questionable Medicare claims. The system, which will be used nationwide, has the potential to implicate countless medical facilities around the country in Medicare fraud scams.

The software uses so-called "predictive modeling" to identify potentially fraudulent health care claims. It has the power to examine millions of Medicare claims and, in conjunction with tips from informants and a list of known fraud suspects, identify which claims may be bogus. Two common tactics used in Medicare fraud scams are particularly susceptible to this computer analysis: the use of stolen identities and the recruitment of conspirator patients who make trips to medical facilities in several areas to make similar claims.

The computer software was tested in South Florida due to the prevalence of Medicare fraud cases here. Of the more than $2.3 billion in fraudulent claims that led to criminal charges since 2007, $1.85 billion occurred in South Florida. More Medicare fraud criminal prosecutions occur in Florida than in every other state combined.

One potential benefit of the computer system is that it may be used to exclude Medicare payments to those suspected of fraud, rather than prosecuting them after the claims have been paid. In the case of a person who is wrongfully accused of fraudulent billing, this would give them a chance to respond, rather than face federal criminal prosecution. This and other consequences of the new computer program should be reviewed carefully in the coming months and years.

Source: The Los Angeles Times, "Medicare anti-fraud system launched," William E. Gibson, 10 July 2011

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