Medicaid fraud, which is adding to today's exorbitant health-care costs, nationally is committed by only 2 percent of providers. But that small percentage has a significant effect.
"That involves $1 of every $5 spent for health care in government-funded programs," said Susan Jones, chief agent for the Medicaid fraud section of the Utah Division of Investigations.An official for the Utah Medical Association believes that figure is "way too high" for physicians.
"But you don't know for sure," said Brent Rufener, director of government relations. "That's why they call it fraud."
Robert Burton, vice president of the Utah Hospital Association, applauded the state's effort in investigating fraud. "However, as far as we are aware, there never has been any fraud committed by our hospitals," he said. "In fact, there have been cases where hospitals have discovered they overbilled, and corrected the problem themselves by notifying the state."
In Utah, not unlike other states, investigators are having difficulty finding the culprits. But they know that in every one of the cases, the motivation has been money. "There's a definite greed factor," Jones said.
"Some of them (health-care providers) get caught up in trying to maintain a lifestyle," added Dennis Kroll, a deputy attorney general assigned solely to prosecute Medicaid fraud.
"Divorce settlements and BMWs cost a lot of money. Some of them see Medicaid funds as an easy way to make up any shortfall."
Investigators, vigorously delving into the problem locally, maintain Medicaid fraud is easy to pull off, but hard to prove.
According to Jones, the most straightforward way physicians commit fraud is to charge for services they don't provide. Another is to misrepresent the services provided, so-called "upcoding."
For example, she said, a physician conducting a mere follow-up visit, could obtain a higher reimbursement by billing for a comprehensive examination.
Jones said that in the pharmaceutical industry, the two biggest problems are "shorting" billing for more pills than dispensed and "kiting" billing for a higher-strength medication than was actually dispensed.
Hospitals in Utah are reimbursed by Medicaid a designated amount for each of nearly 500 procedures. Those institutions, to gain additional Medicaid money fraudulently, Jones said, could bill for more services than were actually provided.
Medicaid, which covers low-income and medically needy patients, is supposed to be the "payer of last resort."
"Yet we have problems with some providers billing both third-party carriers and Medicaid and not letting the other know," Jones said. "That way the providers get a double payment."
Jones said the medical and hospital associations, the Utah Pharmaceutical Association and the Utah Health Care Association have supported the division's effort to curb Medicaid fraud.
"But they do tend to protect their members," she said. "At the same time, if there are bad apples out there, they are as concerned as we are about getting rid of them."
"We certainly oppose fraudulent billing practices or fraud of any kind in physicians' offices," Rufener stressed. "We wouldn't protect our members who are committing the fraud. In fact, if something of that nature is brought to our attention, where a physician has been convicted of fraud, we have a disciplinary mechanism."
However Rufener noted that not all Utah physicians are required to be members of the Utah Medical Association in order to practice medicine in the state.
He also cautioned that, "While investigating fraud, the division needs to understand that physicians are treating patients, and what would concern us is heavy-handed investigation that would unnecessarily get in the way of this treatment."
While Medicaid fraud can be a second- or third-degree felony punishable by up to 15 years in prison, Kroll said prison terms are rarely imposed.
"These are usually upstanding members of the community with no criminal histories whatsoever," Kroll said. "It seems difficult for the courts to impose stiff prison penalties. Instead, we see fines and restitution."
But relatively small fines. Only $78,000 was recovered by fraud investigators last year.