The following is a response from the Canadian Expat Association (CEA) to the CHCAA article entitled “Canadian Expats Getting Free Health Care?” published on May 15, 2008 on this website.

In a bold move to ramp up efforts to combat health care fraud in the United States, members of the health care industry have created the national Consortium to Combat Medical Fraud.

The Consortium is comprised of organizations from government, law enforcement, and the insurance industry. The founding members of the consortium include the Coalition Against Insurance Fraud, the National Health Care Anti-Fraud Association, and the National Insurance Crime Bureau, along with participation from the Federal Bureau of Investigation and Department of Justice.

Health care fraud pervades the entire health care industry and is becoming increasingly sophisticated. It is perpetrated by individual fraudsters as well as organized crime syndicates. The Consortium was designed to respond to the broad scope of health care fraud and the need for a multilateral, more integrated approach to the problem. The consortium will harmonize the efforts of these organizations by facilitating education and data sharing to better detect and prevent health care fraud.

As technology utilization in health care expands, so will the complexity of fraud. The emergence of electronic health records and insurance claims will undoubtedly give rise to increasingly sophisticated fraud schemes, further strengthening the case for greater cooperation within the health care industry and beyond.

The CHCAA has consistently cautioned that health care fraud is an equal opportunity crime that can be committed by any participant in the health care system. According to a recent report by the US government, it seems that this statement can apply even if the participant is six feet under ground.

The report stemmed from an investigation by the Senate Homeland Security Investigations Subcommittee, which revealed that approximately 500,000 claims were submitted to Medicare by deceased doctors over a seven year period (2000-2007) for durable medical equipment such as walking aids and wheelchairs. The panel estimates that Medicare lost between 60 and 92 million dollars over the given time period.

Each Medicare doctor is issued a unique provider ID (UPIN) when they register to practice. This number is then used by Medicare to make payments for the services they render. Unfortunately, Medicare does not always receive a notice that a particular physician has passed away. As a result, anyone who has access to that doctor’s UPIN can fraudulently bill Medicare for services or products and pocket the proceeds. The senate investigation found that fraudulent claims were submitted on behalf of 16,000-18,000 deceased doctors. Subcommittee Chair Senator Norm Coleman (R-MN) expressed shock at the magnitude of the problem, saying that “Medicare is a noble program and it is quite disturbing that so many people would try to exploit the program for their own gain.”

This is not the first time this phenomena has been uncovered. In 2001, the Inspector General of the US Department of Health and Human Services made a number of recommendations to address the problem that included issuing new provider ID numbers, but few of these suggestions were adopted. Currently, the government is planning to cross check provider information with Social Security status reports. Hopefully this will allow Medicare to track the status of their physicians and regularly update their records accordingly. Critics suggest that a lack of resources prevents these measures from going far enough because they fail to determine or address the actual source of the problem.

This is an excellent illustration of provider identity theft. It further underscores how the introduction of systems to manage massive amounts of provider data is a critical step in detecting and preventing health care fraud.