Medicare

Health care fraud and abuse has added billions to the nation's tab for medical expenses. This report focuses on one insurance fraud scheme that investigators say may be the most massive case of health care fraud ever uncovered, one that came to involve hundreds of doctors, several medical laboratories, and an estimated $1 billion in phony claims to health insurers. Known as the "rolling labs" scheme, the scam worked as follows: Vans were driven to nursing homes, health clubs, and even church parking lots where a battery of tests of questionable medical value--everything from blood flow analysis to ultrasounds of the abdominal cavity--were offered to all comers. Patients were literally scared up through telephone calls or letters warning them about the dangers of undetected health problems and urging them to undergo free physicals. To justify the tests and obtain Medicare payments, the operators used doctors who often would simply make up fictitious diagnoses. The rolling labs also solicited kickbacks or "referral fees" from other laboratories for referring patient specimens to them for more testing. This report reviews Medicare's involvement in the rolling labs operation. GAO assesses the extent of false claims paid by the Medicare program, the success of Medicare's efforts to recover these monies, and the program's vulnerabilities to similar fraudulent activities.

GAO found that: (1) although Medicare experienced some success in identification and prosecution of fraudulent laboratory operators, many fraudulent claims were unrecovered; (2) physicians avoid liability for repayment by failing to respond to Health Care Financing Administration (HCFA) and carrier collection letters, stopping operations and forming new corporate identities, and using group practice billing; (3) recovering fraudulent claims concerning unnecessary tests remains difficult due to the required burden of proof; (4) pursuit of fraud cases through civil procedures is hampered by a lack of interagency cooperation and critical missing files; (5) inadequate monitoring of physicians' referral patterns, the ease of obtaining multiple provider numbers, and the failure of provider information regulations to exclude past violators continue to make Medicare vulnerable to fraud; and (6) some carriers have developed computerized claims edits to automatically suspend claims payments, and HCFA requires carriers to establish separate fraud investigations branches, but reduced Medicare funding may constrain and adversely affect investigations and reviews.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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