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Medicare claims database remains potential treasure trove for fraud investigators

By Phillips & Cohen LLP

Although the Medicare claims database is currently regarded as a ?gold mine? for medical fraud investigators, most of the data remains unavailable to the public. The database contains electronic records of bills paid by Medicare for medical procedures, and is one of the most telling sources of information regarding health care spending in America.

The Wall Street Journal, in conjunction with the nonprofit Center for Public Inquiry, was able to obtain information on 5% of all Medicare beneficiaries over an eight-year period, at a cost to the government ?substantially reduced? from the requested $100,000. Additionally, WSJ was required not to publish the names of any particular doctors or Medicare providers. That information has remained confidential from the public since the American Medical Association sued the government to keep secret payments made by Medicare to individual doctors over three decades ago.

Although the information obtained by WSJ represents only a small sample of Medicare beneficiaries, they were still able to identify doctors whose administration of tests and procedures stands out as a statistical aberration, indicating high earning for those doctors and a high likelihood of fraud. Efforts to make the Medicare claims database available for public scrutiny have so far been unsuccessful.

Full post as published by False Claims Act - Qui Tam on October 27, 2010 (boomark / email).