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Medicare Fraud Detection System Increases Likelihood of Medicare Fraud Investigations

Posted by Ron Chapman

Last month the government opened a $3.6 million anti-fraud command center in another effort to reduce Medicare fraud. Since 2009 the government has been aggressively implementing measures to reduce Medicare fraud, which is estimated to cost over $60 billion annually. The Affordable Health Care Act is the driving force in the increase of Medicare fraud detection, adding new legislation and $350 million from congress over the next ten (10) years to combat Medicare fraud.

While Medicare fraud is a growing problem in the U.S., a very small percentage of the 1.5 million participating Medicare and Medicaid physicians commit fraud. The aggressive anti-fraud techniques are likely to cause problems for all Medicare and Medicaid participating physicians.

Last year the Medicare Strike Force implemented a $77 million computer system designed to review Medicare billings and detect fraud. The system is similar to fraud detection programs used by credit card companies. The system had little effect last year but that is expected to change. The new command center has a team designated to developing detection models for the computer systems that will detect billing errors and flag them for investigation. To add to that, the new health law gives the government authority to withhold Medicare payments for flagged billings. If the system is anything like credit card fraud detection systems, physicians may face unnecessary Medicare fraud investigations and withheld payment for billing errors, clerical mistakes and other billing activity not intended to be fraudulent.

Medicare and Medicaid participating physicians should be aware of the new anti-fraud detection techniques in order to avoid possible unnecessary investigations and payment delays. But, as most credit card users have experienced, sometimes there is nothing you can do to avoid being flagged for fraudulent activity. If you are faced with a Medicaid or Medicare fraud investigation, please contact our Medicare fraud attorneys in Florida or Michigan. While there may be no truth to the accusation, the risk of potential sanctions far outweighs the cost of hiring an attorney.