A Medicare beneficiary checked his Explanation of Benefits form and found something that didn’t make any sense.
It was an $8,000 charge for infusion services.
The man knew he had never received medical infusion. In fact, he had not even been to a physician for a long time.
He turned the matter over to Blue Cross and Blue Shield of Georgia, which operated his Medicare Advantage health plan.
The case led to a $1 million fraud recovery, says Alanna Lavelle, a fraud investigator for WellPoint, the parent company of Blue Cross of Georgia.
The Atlanta area is a hotbed of health care fraud, says Lavelle, director of investigations for WellPoint’s health plans in the Central and Southeast regions.
Many perpetrators have moved to Georgia from the south Florida area, where health care fraud has been rampant and has drawn a heavy crackdown from law enforcement.
When she took the WellPoint job after spending 25 years with the FBI, “I was just amazed at the cases of fraud,’’ says Lavelle, who is based in Atlanta. Overall, the number of fraud cases is increasing, she says, even though less than 1 percent of doctors are involved with such schemes.
“Atlanta has so many hospitals, so many doctors, there’s an easy fit [for fraudulent providers] into the market,’’ says Lavelle.
“We have to stay as smart as the crooks,’’ she says. “We have to stay ahead of the curve. The crooks are getting smarter and better.’’
A black market in painkillers
The leading areas for fraud include chiropractic clinics.
Blue Cross of Georgia recently investigated an Atlanta-area chiropractic group for suspicious billing patterns, and detected millions of dollars in fraudulent claims. The investigation led to the sentencing of a chiropractor to 58 months in prison; he was also ordered to pay $6.6 million in restitution.
Another fraud target centers on prescription drug abuse. “Pill mills’’ and fraudulent pain management clinics have popped up in Georgia and adjoining states, illegally selling prescription pain medication. “There’s a tremendous prescription drug abuse problem in the Southeast,’’ Lavelle says.
The National Health Care Anti-Fraud Association says other fraud target areas include durable medical equipment, home health care, and community mental health centers.
“Anywhere you can get into the system and bill quickly’’ is a ripe area for perpetrators, says Louis Saccoccio, CEO of the Anti-Fraud Association. “You can start a medical supply business without being a licensed medical provider.’’
Fraud accounts for tens of billions of health care dollars a year, Saccoccio says. His association brings together government agencies and private health insurers to share information about fraud.
The Atlanta area is a current hot spot for fraud, even though it’s not on the Justice Department’s list, says Lavelle.
WellPoint has collaborated with other private health insurers, sharing information about fraudulent providers, as well as government agencies, she says. (Here’s a recent GHN article about Georgia’s Medicaid fraud task force.)
Impostors in the system
Medical identity theft is another huge problem. A rogue health care employee may sell Medicare, Medicaid or health plan numbers and names to someone who sets up a bogus clinic. “It could be a post office box,’’ Lavelle says. “They file claims to different carriers.’’
Physician IDs can be stolen as well.
“We’re doing everything we can to stop that activity,’’ Lavelle says. “We’re looking for highly aberrant claims.’’
Lavelle and Saccoccio say consumers should guard their medical ID numbers zealously.
“They should consider these numbers like credit card numbers,’’ says Saccoccio. “They should not give out the number over the phone if they don’t know who they’re giving it to.’’
And like the Blue Cross Medicare member, people should check their Explanation of Benefits form, he says.
Consumers can also be fraud detectives.
“If they go to a doctor or clinic, and something doesn’t seem right, they should report it,’’ Saccoccio says.