WRAL Investigates

Medicare fraud easy to disguise; asking questions important

Posted November 8, 2010 6:00 p.m. EST
Updated November 8, 2010 7:20 p.m. EST

WRAL Investigates

— Complicated billing codes can make Medicare fraud easy to disguise, and as one Medicare recipient told WRAL Investigates, it’s important to ask questions about your statements.

Nancy Ormond said she saw WRAL’s recent stories about Medicare fraud and wondered if something underhanded was going on with her own Medicare statement. She started renting a sleep apnea machine five years ago from a company called Lincare. Every six months, Medicare was billed $218 for service and maintenance, and her co-pay was $20.

“But mine has never been touched by the company since I got it,” Ormond said, noting that Medicare told her the charge was allowed, but wouldn't say why. “They gave me no explanation. As a matter of fact, I asked if I could have a letter stating that, and she said ‘no.’”

Marianne Durling, an insurance expert who teaches billing codes, said someone should be coming out to calibrate the sleep apnea machine every so often to make sure it’s set at the correct levels, to make sure it’s functioning and to clean out the filters.

Durling said Ormond’s charge looks legal; however it still left her with questions.

WRAL Investigates tried to ask Lincare about the charge, but the company did not return any phone calls. Lincare has been hounded by problems in the past. It has been sued for overbilling and, in 2006, agreed to a $10 million settlement with the government for kickbacks to doctors for sending business the company’s way.

WRAL also asked Medicare to review the charge again. Ormond’s case might just come down to confusing billing practices, nothing sinister, but Durling says there's no doubt Medicare is overloaded with serious fraud cases.

“By the time they finally catch it, it’s usually years down the road,” Durling said.

Those who are caught usually don't have to pay back as much as they stole.

In March, WRAL cameras captured one guilty man, Kalu Kalu, running out of court in Raleigh as quickly as possible to avoid the cameras. He is estimated to have illegally taken $12 million from the government in scooter fraud. As part of a plea deal, he was supposed to pay back $4.6 million.

WRAL also reported on a father/daughter team in Wilmington who admitted their clinics were committing the same crimes, which included taking money from Medicare for things never provided or needed, such as motorized scooters.

As part of the new Health Care Reform, $350 million has been added to fight Medicare fraud. Changes also include stricter sentences for those who commit crimes and more oversight for companies allowed to bill Medicare.

“I kind of figure, I’m 47, I figure by the time I hit Medicare age, it’s going to be bankrupt,” Durling said. “It’s not going to be there unless there’s a huge change in the system.

During 2009, the federal government won or negotiated approximately $1.63 billion in judgments and settlements involving health care fraud cases and proceedings, according to a U.S. Department of Health and Human Services report.