Fraud

[NC29mom]

I wish I could open a business in which I investigated, and reported citizens for fraud. Medicare/Medicaid/SSI/Disability/ Food Stamps.....you name it.

As a society, we have become dependant upon our government for everything (not everyone, of course). There are young people fully capable of working a job (might not be the job they want, or pay they need, but its the job they qualify for) who live off us taxpayers. While our elderly (who couldn't work if they wanted to), live off pennies a month. Its utterly embarrassing and disgusting.

Im speaking from my personal experiences. Not trying to step on any toes, or start an argument. ...just wondering if such a business could exist? The government doesn't seem interested in doing anything but GIVING our hard earned dollars AWAY.

Does anybody know if this could be a legit business? Investigating and reporting government fraud?

[NedRN]

Fraud by individuals is fairly rare when you consider the millions of claims. The government gets more interested when certain categories get an upswing, but that is larger fraud by providers. Private insurers are similar. I could not get Blue Cross interested in over billing by my dermatologist.

I don't think anger at the acts of a few is a good reason to change careers, even if such a job existed. Every insurance company (including the government) has well paid actuaries with a mission to minimize expenses and optimize operations. That does include acceptance of a certain level of fraud. As a kind of a parallel, you would be shocked at the level of bad debts credit card companies find acceptable. Of course we all pay for it with higher taxes, premiums, or interest. Competition keeps fraud in balance, at least in our society. We don't have to put up with the kind of government fraud common in many other countries.

[Altra, BSN, RN]

I wish I could open a business in which I investigated, and reported citizens for fraud. Medicare/Medicaid/SSI/Disability/ Food Stamps.....you name it

Each of the agencies (state and federal) which administers the entitlement programs you name are subject to different rules and regulations and employ case workers and others whose job description includes preventing/addressing fraud.

[LadyFree28, BSN, LPN, RN]

Each of the agencies (state and federal) which administers the entitlement programs you name are subject to different rules and regulations and employ case workers and others whose job description includes preventing/addressing fraud.

^This.

My mother did this the last 10 years before she retired...she still is in contact with her co-workers, especially the one who took over for her.

TRUST me, there are states who are catching people and have caught people who are defrauding social programs-should there be more?? Now THAT's the question...

Also, CMS contracts nurses to do chart reviews to ensure that providers and hospitals are getting properly billed-they send nurses out to ensure and show PROOF that what a MD and/ or a nurse documents matches up to the reimbursement. If they don't, the providers don't get paid. It is tedious work, but if it isn't documented, it wasn't done nor it gets paid for. They have a total different way of reimbursing category beyond the ICD coding system...only a few of those categories are grouped under what is considered billable, especially for Medicare. I have learned what they considered "billable" depending on coverage...and it's not a lot.

So if anyone is committing "fraud", they're certainly not getting their "fraud" covered...they are getting a 20% bill every time, which adds up. THAT can be a burden. I think that may be a reason why they don't go after "the small fish" per say...they may not collect. Now, a hospital or a physican...more chances to not reimburse helps a CMS situation more than the alleged "fraudulent" individual...