Asking out of genuine intellectual curiosity, not with political or other overtones (even with the highly political character of the news today).
The fraud was perpetuated against Medicare, which is the US-run insurance plan for people 65 and older and people with disabilities. Nearly 20% of the population is on Medicare.
Universally letting everyone on to the plan would have actually allowed them to run the fraud on everyone, not just people on Medicare.
They do. Private insurers get defrauded all the time just like Medicare does.
https://www.propublica.org/article/we-asked-prosecutors-if-h...
Investigations are a cost-center. Government can staff investigators; private insurers just factor the fraud into next year's premium hike.
> To put that record in context, take a look at the state’s Medicaid program, which covers about 13 million low-income people. During fiscal 2017 and 2018, the program’s fraud unit filed criminal charges against 321 fraudulent medical providers. It garnered 65 civil settlements and judgments and recovered more than $93 million, according to the state attorney general’s office.
> A rigorous search for civil lawsuits filed by private health insurers over fraud in California turned up just one case in 2017 and 2018. Experts said insurers rarely sue over fraud because of the high cost of litigation.
> I tracked down a dozen or so investigators who once worked for insurers, and they all said the same thing: Insurers don’t police fraud as much as they could because it hurts the bottom line.
Maybe 6 is Medicaid through a managed care plan.
House of Representatives and Senate offices will provide health coverage to Members of Congress and designated staff through the Small Business Health Options Program (SHOP).
https://www.opm.gov/frequently-asked-questions/insure-faq/he...
Most of the 'fraud' that doctors complained about where I lived in Italy was old people coming in with mostly imagined complaints because they're lonely and don't have anyone and a doctor visit is free. Which is kind of sad, but... not the same level of problematic.
I don't think that's a relevant analogy at all. In this case, the doctors were the ones perpetuating the fraud. Not the patients, not the insurance company.
Anytime the person paying is not the one receiving service, the appeal of fraud goes up. When the person paying is not paying with their own money the appeal goes up and a TON of incentives argue against finding fraud. At least in govt, there is sometimes a willful blind eye because finding fraud causes a huge headache and you don't benefit or get paid more. In fact, if you are taking an administrative fee to manage the program, reducing expenditures can hurt your own budget.
I have traveled internationally where folks paid cash for services. It was a bit crazy - they would basically hold you hostage until you paid a bill / impound your car etc. BUT you could buy many drugs OTC (no DR visit even required) and the layers of things like approvals, pre-approvals, billing and billing codes etc simply didn't exist.
Private insurers get defrauded just like Medicare does. They just don’t care; it means they can raise premiums.
https://www.propublica.org/article/we-asked-prosecutors-if-h...
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The province’s 12 top-billing doctors — who received payments of between $2 million and $7 million in one year — are overcharging the Ontario Health Insurance Plan, documents obtained by the Star suggest.
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Among additional “concerns” alleged in the report:
- Three specialists “inappropriately delegated” duties — for which they billed OHIP and which were supposed to perform themselves — to unqualified individuals to undertake.
- Six claimed to have worked between 356 and 364 days of the year.
- Eight recorded notably high volumes of claims and/or patients. One radiologist, who worked 332 days, billed for 100,000 patients, indicating that more than 300 scans were interpreted per day, the report stated.
- Eleven billed OHIP incorrectly.
- An obstetrician/gynecologist billed for seeing male patients.
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