Medicare Turns 50


As an infant in 1966, Medicare served 19 million beneficiaries with a budget of $10 billion. As it enters middle age, celebrating its 50th anniversary on July 31, 2015, it touts a $600 billion budget. That’s quite a weight gain. More troubling is that an estimated $18 - $60 billion (3-10% of the total budget) is lost to fraud. 

How is the government celebrating Medicare’s big birthday? One way is by increasing its fight AGAINST fraud. What does that mean for healthcare providers?

Did You Know?

In 1965, government experts projected that Medicare would cost $12 billion in 1990. It actually cost $107 billion. Today, Medicare accounts for 14% of the total federal budget. Because of the aging Baby Boomer generation, Medicare enrollment is projected to rise from about 55 million in 2015 to more than 78 million in 2030, while Medicare spending could increase to more than $1 trillion by that time. 

A Few Bad Eggs
Per § 3729(b)(1) of the False Claims Act, knowledge of false information, or fraud, is defined as being actual knowledge, deliberate ignorance of the truth or falsity of the information, or reckless disregard of the truth or falsity of the information. Remember, a person may not violate the False Claims Act by inadvertently submitting a false claim to the government. That means “mistakes” might not be considered fraud. Good! Should you still be concerned if nobody in your organization is a thief? Yes.
The FBI’s examples of possible fraud include: upcoding services or items, billing for services not rendered, and issuing kickbacks. Therefore, if a billing mistake results in an inappropriate payment, your organization may need to prove that the mistake was “innocent.” Based on our experiences working with clients, innocence can be hard to prove.

Education is Your Best Protection
One of our most popular services is providing education to all levels of healthcare providers’ staff. In particular, we frequently bring clients peace-of-mind that their MDS coordinators are appropriately trained so that RUG payments are accurate and supported in the clinical record. To learn more, click here