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What Is Medicare Fraud?

Pharmacy fraud has become a rampant problem across the state of Florida as drug traffickers conspire with doctors and patients to cheat the Medicare system. The individuals involved have become more organized and have taken a systematic approach to stealing money from Medicare. In total, the country is continuing to lose as much as $60 billion to $90 billion a year to Medicare fraud.

Medicare is our country's health insurance program for people age 65 or older. However, there are certain people younger than 65 who can qualify for Medicare, including those who have disabilities, permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig's disease). The program is financed by a portion of the payroll taxes paid by workers and their employers, and helps with the cost of health care for those eligible.

Individuals involved with Medicare fraud are those who knowingly trick Medicare into receiving inappropriate payments from the program. This deceit can be achieved through a wide spectrum of ways, including false statements or representations by patients, false payments, or false statements or representations with respect to the condition or operation of an institution. See United States Code § 1320a-7b. For example, a Medicare patient in South Florida had been diagnosed as HIV-positive and was living in a boarded-up mobile home. Medicare was providing this individual money to get the treatment he needed. However, instead of getting the drug treatment, the patient was willingly accepting a vitamin mixture from a bogus clinic in exchange for the cash. There are other examples where individuals are claiming to be health-care providers while collecting Medicare Part D prescription drug benefits for patients who never receive them. The investigations surrounding the Medicare Part D incidents have almost quadrupled over the past five years in the South Florida region.

Recently, a hearing before the Senate Committee on Aging was held in order to assess anti-fraud enforcement measures and to determine whether investigators need more resources or legal authority to prevent criminals from tricking Medicare and its patients. One of the resources already in place is The Affordable Care Act. This act has bolstered enforcement by requiring criminal background checks of prospective Medicare providers.

Due to the high concentration of prescription-drug fraud in Miami-Dade County, a crackdown called ground zero for Medicare fraud has been implemented. This crackdown has pushed fraudulent operations farther north in other areas of Florida. Brian Martens, assistant special agent in charge of the Miami inspector general's office for the Department of Health and Human Services noted "as you put stronger efforts to stop it in one area, it's like an anthill, it's going to move to other places." Florida isn't the only place where this type of fraud is a problem. The Justice Department reported 377 new prosecutions of health care fraud in fiscal year 2013.

Source: Sun Sentinel, Pharmaceutical fraud spreads in Florida, William E. Gibson, 3/26/14

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