Why would any physician want to deal with Medicare for as little as it pays???
Most physicians no longer work in solo practice and the hospital or clinic they work for usually takes Medicare patients. Being qualified to receive Medicare reimbursements is very important to maintaining incomes and private insurance companies tend to look at Medicare approval as a surrogate validation. If you are removed from Medicare reimbursement eligibility, the private insurance companies will drop you from eligibility, too. At least that’s how it works in this neck of the woods. The docs around here care very very much about Medicare even if they rarely see a Medicare patient.
Most fraud (real fraud) involves minority communities and is too hard for the Feds to prosecute, for a number of reasons.
Pseudo-fraud, OTOH (failure to adhere to all 70 000 pages of the constantly changing regulations) is easy to prosecute, since under administrative law accused parties are guilty until proven innocent, and technical violations are easy to find in every practice.
Then there are “frauds” like charging for a consultation after Medicare declared 2 years ago that they would not recognize consultations any more. Consultations, you know, when a primary care doctor calls a specialist to see you?
So, Medicare decreed that when a doctor does a consultation for a Medicare patient, he must bill instead for a routine hospital or office visit (because the Feds don’t recognize consultations anymore). Or, I suppose, you could do it for free.
This has created thousands and thousands of charges that are arguably “fraudulent”. Obviously, when I do a consult, the medical record has to reflect 1) that I was asked to do it; 2) what my opinion is; 3) what I recommend; and 4) the discussion I had with the referring doctor. The problem is, this note does not meet Medicare criteria for a routine visit.
So, in theory, any “routine visit” charges since 2011 that are really for consultations could be prosecuted as fraud.