Gov't wants more whistleblowers for Medicare fraud

Dr. David Ketroser
Minnetonka neurologist Dr. David Ketroser reported what he believes are fraudulent Medicare charges by Mayo Clinic in Rochester. Mayo denied those allegations, saying it was "a billing error," which it says it has rectified and made repayments for.
MPR Photo/Dan Olson

Federal officials are expanding anti-fraud efforts as they work to stem the flow of billions of dollars in fraudulent payments out of Medicare every year.

This year, Medicare will pay out around $500 billion to 46 million beneficiaries, and Chad Blumenfield, an assistant U. S. Attorney in Minneapolis, says the program has been viewed as an easy target for fraud.

He and his colleagues are on the lookout for attempts to swindle the Medicare system.

Obama administration officials say Medicare and Medicaid -- the federal health care program for the poor -- improperly paid out $54 billion last year.

Blumenfield says part of the problem is that Medicare aims to pay doctors, hospitals and clinics quickly, which means less time devoted to checking that every payment is on the level.

"When you want to pay providers in a timely way, sometimes there are fewer checks at the front end and there's more checks at the back end," he said.

The government is counting on whistleblowers to play an even larger role in ferreting out Medicare fraud.

One first-time whistleblower, Dr. David Ketroser, a neurologist based in Minnetonka, alleges the Mayo Clinic in Rochester billed Medicare for tests on his patients that weren't performed.

Being the whistleblower, Ketroser said, has been a struggle.

"We've been doing this for three years," he said. "During those three years we've been trying to explain to the government why we're right and why they should do this."

In an out-of-court settlement, Mayo admitted no guilt.

In A statement, Mayo spokesman Bryan Anderson said: "Upon discovering a billing error in 2007, Mayo corrected it and voluntarily refunded $242,711 to the government.

"The error was identified and corrected long before Mayo became aware that a sealed complaint had been filed, and before Mayo was notified that the Department of Justice was evaluating whether to become involved in the complaint. Mayo has fully complied with the law."

In a similar case, whistleblowers whose identities have not been made public allege the Apple Valley Medical Center in the southern metro over charged Medicare for tests on patients.

The clinic gave back nearly $200,000 to the government, but admitted no guilt in an out-of-court settlement.

The recently passed federal health care overhaul contains an additional $350 million beyond what is already being spent to fight Medicare and other health care fraud.

John Hammarlund, the regional Medicare administrator based in Chicago, said the expectation is the investment will pay off.

"The Congressional Budget Office estimates that for every $1 that we invest to fight fraud yields approximately $1.75 back in savings," he said.

Hammarlund says last year the government, with the help of its investigators, whistleblowers and others, recovered four billion dollars.

Fighting Medicare fraud has become such a big and potentially lucrative effort that hundreds of private practice attorneys represent whistleblowers with a hope of winning a portion of the settlement.

The government is also urging this country's 46 million Medicare beneficiaries to play a part.

Charlene Jebens
Former registered nurse Charlene Jebens of Brooklyn Park is a volunteer for AARP. She reports any tests, procedures or medical equipment billed to Medicare on behalf of people she knows if she thinks the charges are fraudulent.
MPR Photo/Dan Olson

Charlene Jebens, of Brooklyn Park, is part of an AARP fraud watchdog group. She said every beneficiary needs to check his or her Medicare statement.

"Make sure what is on there is a correct service," Jebens said."Sometimes what happens is your social security number gets somehow used to bill for all kinds of things that you don't ever even receive."

The stepped-up enforcement also includes hiring contractors for data mining. Assistant U.S. Attorney Blumenfield said the contractors scour claims and other information to see if Medicare fraud seen in other parts of the country is popping up in Minnesota.

There are also increased fines and other penalties for people involved in Medicare fraud.

Health care companies for example can be put on what amounts to probation by Medicare if they're caught stealing. They are then watched for five years or more for repeat transgressions.

Not everyone is impressed with the government's tougher fraud measures.

Sen. Charles Grassley, R-Iowa, said even with all the added enforcement, the Medicare fraud conviction rate is nearly level with years past and wants to know why.

Some members of Congress want a stalled bill passed that would effectively ban executives of health care companies found guilty of Medicare fraud from working in the health care field, similar to sanctions imposed on executives in the financial services industry.