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PPACA/Obamacare and Medicare fraud

Among the hundreds of pages of the PPACA are passages addressing provider fraud, a far-too-common and far-too-costly issue that has long plagued the program.

The good news is, things seem to be getting better.

CMS just reported they recovered a record $14.9 billion in 2011 and 2012 from anti-fraud prosecutions and judgments.  The number of providers kicked out of Medicare more than doubled in the two years after PPACA was passed. And the most recent large action saw 89 individuals charged with $223 million in false billing.

One occurred in Miami (shocking, I know), where a local TV celeb was busted for allegedly falsely billing Medicare some $20 million for home health care services for diabetics…(you gotta see this picture of the alleged perp…)

There are a bunch of reasons for the increased success;

  • PPACA allocated an additional $350 million over ten years to anti-fraud efforts;
  • the FBI has dedicated more resources to the effort,
  • CMS investigations staff and resources have been increased and given more authority and a more prominent position in the Department;
  • computer programs designed to identify potential fraud have been developed and improved, and
  • rewards for tips may be drastically increased – up to a maximum of $9.9 million.

That’s all good – but every time I see a TV ad for that hoverround chair I think there’s still  some rather significant “opportunities” to reduce taxpayers’ burden.

If those companies can afford to stuff my cable box full of adverts, they are making too much profit.

2 thoughts on “PPACA/Obamacare and Medicare fraud”

  1. How about using the15 billion in recoveries to cover half of the 32 billion of forecasted revenue that the excise “cadillac” tax revenue is expected to bring in to fund PPACA and give a pass on penalizing US employers for wanting to purchase decent health coverage for their membership. Oh, but that would only generate jobs…

    1. Steven
      Thanks for the comment. Fortunately the coverage available thru the exchanges – even at the highest levels – looks like it will come in under the Cadillac threshold. If employers and labor want higher levels of coverage than it seems only fair that those higher benefits be subject to taxation.

      I’d suggest it is up to the insurers and health plans to develop plans that will provide ample coverage at competitive rates. I’d they fail to do so, they will fail in the marketplace.

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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