Jordyn Hughes – Medicare and Medicaid are government run insurance programs that provide healthcare to different qualifying individuals. Medicare provides health coverage to people 65 years of age and older, or under 65 with a disability, while Medicaid is a state and federal program that provides health coverage to low-income individuals.
Medicare is separated into four different parts: Medicare Part A, B, Medicare Advantage plan (C), and Prescription Drug Plan (D). The health services and prescription drug costs vary on a plan-to-plan basis. Medicaid covers a wide range of services to those qualifying; these benefits include: inpatient, outpatient, nursing facility, home health, family planning, midwife, and doctor’s services. It also includes a variety of occupational and physical therapy services. Medicare and Medicaid reimbursement occurs when a hospital, doctor, or facility provides services to an individual with this insurance coverage and instead of charging the patient, charge the insurance program for reimbursement for services performed.
This leads to a major drawback associated with the federally run programs – when doctors or facilities fraudulently request reimbursement for services not performed or patients not treated. Billionaire, Phillip Esformes is what some would call the El Chapo of Medicare and Medicaid fraud. After a more than decade long conspiracy to defraud the government, FBI agents arrested Esformes in 2016 for what the federal prosecutors called “the nation’s biggest Medicare fraud case” to date. The scheme amounted to over 1 billion dollars in fraudulent billing for medical services, while Esformes pocketed an approximated $36 million through over 250 bank accounts.
The monumental scheme included bribing a system of doctors to “recycle” patients from a hospital to Esformes’ network of nursing facilities and assisted living facilities. It is important to remember that nursing facilities and assisted living facilities do not require a doctor’s order or prescription to admit patients. Once in these facilities, Esformes billed Medicare for a 100 day-long stay per patient. During their stay in these facilities, the healthcare providers would bill for medical services that were never performed and patients’ Medicare numbers were sold to other scammers, who would then continue the cycle of fraudulent billing for services not rendered. When the patient’s Medicare eligibility at the first facility expired, the patient would be moved to another facility to further the scheme.
This triggers a burning question, how is it that one man leads a ten-year long scheme amounting to $1 billion in fraudulent reimbursements without being caught? It could be due to the fact that Esformes ordered those within his circle to bribe Florida regulators in order to receive advance warnings of inspections. It could also be the fact that Esformes ordered those running the facility to physically hide patients who did not qualify for the health care programs when inspections occurred. Most likely, it could be due to the fact that Medicare and Medicaid progra are poorly policed are therefore easy targets for those hoping to scheme the federal government.
The federal government’s spending on Medicare was an estimated 15% of the total budget in 2017 alone, with most estimates predicting a rise in the funding attributed to healthcare. Yes, this is a large amount of money when looked apart from the budget as a whole, but it is doubtful that a large portion of this budget goes to policing those who take advantage of the government, the elderly and the disabled. By expanding regulation and policing of these programs, the public’s trust and knowledge in these programs could be increased.
