KINGMAN - Mohave County isn't a hub of Medicare fraud like, say, Miami, but enough happens that people need to be on guard against it, a local advocate who works with seniors said recently.
"Most doctors and health providers, about 98 percent, are honest," said Dale Gibson, a benefits counselor for the Western Arizona Council of Governments in Kingman. "And I don't think the problem is that bad in Mohave County. But people here still have to be on the alert to Medicare fraud."
According to the U.S. Department of Health and Human Services, fraud costs the Medicare program at least millions of dollars each year, although no specific amount is available. U.S. Attorney General Eric Holder suggested there is an estimated $60 billion to $90 billion in Medicare fraud annually in a program that pays out at least $500 billion each year.
In Mohave County, said Gibson, there is a variety of activity that could qualify as fraud.
For instance, a company sales representative was telling people he also represented Medicare, which he didn't, and another was going door to door offering insurance plans for sale, which is illegal.
Others were calling residents about plans, which is not allowed.
"I get a lot of insurance companies that want to come in to the senior centers and make presentations," said Gibson. "If I have one come in, they all have to come in. They can provide meals, but if attendees sign in for the meals, those companies can't say they signed up for a policy by doing that and send them one.
"We go after those companies, and it's usually an overzealous sales representative from Phoenix."
Other examples include laboratories that break down a bloodwork panel and charge separate fees for each part instead of billing for the entire panel, which is cheaper. Gibson said that borders on fraud because the action is intentional.
Also, it's questionable when a nursing home takes in a patient who has been in the hospital for the Medicare-allowed three days and performs the same tests that were done during the hospital stay.
"Medicare participants get a quarterly summary of what was charged and what was paid, and it's very important for them to look that over," said Gibson. "That's the first line of defense to see if they're getting over-billed. It does happen.
"The key is to catch errors as quickly as possible. And if someone suspects fraud, reports it and it's valid, there is a reward for that."
Fraud includes a health care provider billing Medicare for services or equipment that a patient never received, offering a Medicare drug plan that hasn't been approved by the agency, or using false information to mislead someone into joining a Medicare plan. Also, it includes a company placing the wrong diagnosis on a claim so Medicare will pay it, or advertising "free" medical consultations to people with Medicare.
Gibson said Miami is ground zero for Medicare fraud, with much of it taking place with durable medical equipment, such as walkers, wheel chairs, hospital beds and scooters. Businesses that actually don't exist bill Medicare for the equipment and pocket the money, said Gibson. Other areas of fraud across the nation include ambulance, pharmaceutical pricing, hospice, nursing home and long-term care.
But Medicare is starting to make changes to curtail the fraud, said Gibson, by requiring businesses to post bonds, become licensed by Medicare and bid on projects.
Also, Medicare partnered with the U.S. Department of Justice and sends out "secret shoppers" to stores, doctors and laboratories.
Gibson said the agency is focusing on the habits of providers instead of only going after them if something is blatantly wrong.
"Fraud has been running rampant for years and the government is making inroads, but the dollar amounts are increasing," said Gibson. "I haven't seen a lot of fraud in Mohave County, but I am seeing a lot of errors on the billing codes entered by providers.
"I send potential Medicare fraud cases to the Arizona Attorney General office and they're on it quickly."