The human population is growing at a rapid pace, and in the U.S., this growing population is also aging. The babies born after the Second World War, often referred to as “Baby Boomers,” are now reaching retirement age and eligible for Medicare. The Kaiser Family Foundation reports that almost 10,000 Baby Boomers turn 65 on a daily basis! That’s almost 90 million Baby Boomer eligible for Medicare by 2050.
Moreover, advances in healthcare treatment will allow Baby Boomers to live longer and healthier lives than ever before; however, unless healthcare costs are contained, per-capita expenses will increase and overall healthcare expenses will rise to record-setting levels. Government funded programs like Medicare will experience staggering cost increases, requiring a greater percentage of the government budget to subsidize healthcare expenses, burdening all taxpayers. This challenge – to fund and responsibly manage government healthcare programs given the expected increase in government beneficiaries – is one of the most pressing issues we face in the 21st century.
The appropriate response to manage healthcare costs will be vigorously debated, but one area of wide agreement is the need to identify and root out healthcare fraud.
The Correlation Between Baby Boomers & Medicare Fraud
As more and more Baby Boomers become eligible for Medicare, more and more opportunities for fraud appear.
Medicare fraud may be committed by medical service providers, pharmaceutical companies, nursing homes, or any number of participants in the healthcare arena. All too often the government pays for procedures that were not even performed or were not medically necessary. A medical service provider may order tests that were not part of the treatment the doctor and patient agreed to. The medical service provider then bills Medicare for the costs of the test, making it appear that the procedure was required and medically necessary when it was not. That is fraud.
Another example involves hospitals and medical service providers paying or otherwise incentivizing doctors for referrals of Medicare and Medicaid patients. These kickbacks, although forbidden by the law, are common practice in the healthcare industry. Creative incentives such as free sports tickets and inflated speaking fees undermine the fidelity of the healthcare industry and illegally divert billions of dollars from Medicare and Medicaid programs.
Each year, the Justice Department’s Medicare Fraud Strike Force investigates and charges people with healthcare fraud. These actions involve billions of dollars in fraudulent Medicare charges. For example, Margarita Grishkoff, a former lawyer, pleaded guilty and was sentenced to 70 months in prison for submitting fraudulent Medicare claims amounting to $28.3 million. Her false claims included both kickbacks as well as false reimbursement claims for services not provided. A Los Angeles doctor, Robert Glazer, was charged with fraudulent Medicare billing for prescriptions and unnecessary medical services and supplies. Mr. Glazer’s allegedly fraudulent claims totaled $33 million.
Whistleblowers and Medicare Fraud
As the Baby Boomer population increases, the Medicare Fraud Strike Force has increased the number of investigations and actions involving Medicare fraud, but more needs to be done. Whistleblower programs – programs that protect and incentivize whistleblowers to report fraud against the government – need to be strengthened and supported. Billions of dollars in healthcare fraud recoveries are the product of whistleblowers who courageously came forward to report healthcare fraud. Without this insider information, healthcare fraud would be substantially more difficult to identify and prosecute.
As the Baby Boomer population increases and government healthcare programs feel the burden of additional beneficiaries and higher per capita costs, the need for whistleblowers to guard against fraud and abuse becomes even more important.