This post is in response to a recent article highlighting the rise of prescription fraud. I wanted to highlight some important aspects of the article.

Frequent incidences of prescription drug misuse:
1. Doctor shopping – hopping from doctor to doctor in order to receive medication and deceive the doctor. Patients also go doctor shopping to find a doctor that will “address” all their prescription needs i.e. over prescribing.
2. Manually changing the dose of the prescription. Example: If the prescription is written for 25 pills, they might add a 1 in front of it to make it 125 or a 0 at the end to make it 250.
3. Medical identity theft – stealing a victim’s insurance card and obtaining prescriptions under the victim’s name.
4. Inside cooperation – stealing a doctor’s prescription pad and writing prescriptions.

This list is by no means exhaustive. It just gives you a clue to what is occurring.

What are Pharmaceutical companies doing?
1. Making pills tamperproof – meaning that if they’re crushed for a stronger, more rapid high they become ineffective.
2. Patient medication guides explaining the exact purpose of the drugs and the consequences of misuse.
3. Letters to doctors and additional physician training to end the misuse and inappropriate prescribing of painkillers.

Those last 2 strategies are debatable, but they are necessary steps that need to be taken to combat prescription drug addiction.

How can providers combat the misuse?
1. Electronic health records can help combat this problem. The physician would be able to see that the patient has seen an abnormal amount of doctors and see what the patient was prescribed – eliminating the ability for a patient to be over prescribed.
2. Stop over prescribing – simple as that.
3. Understand the warning signs of users.

Read the full article here.

With weight-loss drugs all the rage these days I thought this post to be especially important. This is in response to an older post about counterfeit drugs. They are out there – even with over-the-counter medications like Alli. Tests conducted by drug maker GlaxoSmithKline show that counterfeit versions of Alli do not contain the active ingredient orlistat but instead a controlled substance called sibutramine. Sibutramine should not be taken without a doctor’s supervision and monitoring. Some frequent side effects include dry mouth, paradoxically increased appetite, nausea, strange taste in mouth, upset stomach, constipation, trouble sleeping, dizziness, drowsiness, menstrual cramps/pain, headache, flushing, or joint/muscle pain.

Counterfeit Alli looks similar to the authentic product, however some notable differences occur with packaging.
1. Outer cardboard packaging missing a “Lot” code
2. Expiration date that includes the month, day and year – authentic Alli only includes month and year
3. Packaging in a plastic bottle that has a slightly taller and wider cap with coarser ribbing than genuine product
4. Plain foil inner safety seal under the plastic cap without any printed words – authentic Alli seal is printed with “SEALED for YOUR PROTECTION”
5. Contains larger capsules with a white powder instead of small white pellets

See FDA’s full report here including pictures.

Remember – be a conscientious consumer and watch out for counterfeit medication, it could have very adverse outcomes on your health.

A new addition is being added to the blog. Our healthcare system is broken and fragmented and patients are usually the ones that receive the brunt of the abuse. Real stories from real patients will highlight the traumatic events that patients have to face in the wake of terminal illness, an accident or any other medical emergency.

Names have been changed to protect the innocent.

A scary night in the ER

“I have been watching my friend for the last 24 hours. First in the ER being monitored by a machine for his heart, oxygen and blood pressure – the alarm is turned off so it doesn’t make any noise – followed by a 6 hour wait for EMERGENCY surgery – hoping that he gets in the cue prior to the onset of internal rupture. I watched patient transport almost pull him out of the room without disconnecting the tubes from the wall – a frustrating reminder that the focus on reform is not about health.

After surgery I was watching him recover and yet again the $200 monitor has the alarm turned off. I thought to myself, ‘I wonder what would happen is there was no one in the room and he couldn’t call out for help?’

My friend received a 2mg narcotic through his IV around 6:00 pm. At 8:00 pm the nurse came back to evaluate for another .5mg of the narcotic. I watched his nurse place the injection on the table, take and enter vital signs into the bedside PC and while I was looking at my notes, the nurse left the room. I asked my friend, “Did the nurse give you anything?” He didn’t know. I looked for injection marks on his right arm – nothing. I walked out and asked the nurse, “Did you give him the injection?” The nurse’s response, “You were in the room the whole time, did you not see me give it to him?”

I took a step back – I am tired and need to turn off my fraud, waste and abuse examiner’s hat. However, I wonder on these points…

1. I believe the nurse stole the narcotic and did not give it to the patient. The next day the floor nurse let me look at the medical record. The patient received the narcotic at 8:00 pm IVP – which means the nurse would have had to ask me to move since I was sitting next to the arm with the IV.

2. The on call surgeon had to wait until the on call surgical staff finished operating on the patient’s rupture appendicitis. He was ready for surgery at 10:00 pm but could not get in until 1:00 am. So what would have happened if the bowel obstruction ruptured any time before 1:00 am? Would he have died in the ER? Been transferred to another hospital?

3. What would have happened on the snowy icy night if an auto accident had been admitted? Would he have been bumped? Did the hospital put their ER in bypass mode?

4. Now what about the ER nurse, did he take the narcotic himself? Was he feeling a little ‘happy’?

The False Claims Act was passed by Congress in 1863 and allows people who are not affiliated with the government (Congressmen, the President etc.) to file actions against federal contractors claiming fraud against the government.

In our current economic forecast with fraud running rampant (the Madoff scandal, the collapse of the financial market etc.) the False Claims Act is still relevant. Even with the abundance of accounting fraud, the major focus of the False Claims Act is still healthcare fraud. According to an article in the American Medical News, “Healthcare cases made up the lion’s share of false claims settlements and judgments in the fiscal year, brining in $1.6 billion, or two-thirds of the total $2.4 billion recouped.

Read full article here.

Healthcare fraud is a huge industry for the ethically challenged in our country. Keep reporting – it is a great deterrent.

A global crackdown on counterfeit drugs has uncovered more than 700 alleged packages of fake or suspicious prescription drugs including Claritin, Viagra and Vicodin. Some of the drugs might have had 3 times the active agreement than normally prescribed, others were placebos and some drugs contained materials typically not found in medications including drywall material, antifreeze and yellow highway paint.

See article for more information.

With the increasingly high costs of prescription medications, many people are turning to the Internet to fill their prescriptions. Internet pharmacies are a hot bed for counterfeit drugs. However, don’t assume you’re safe if you purchase from a brick and mortar pharmacy – counterfeit drugs can make their way into the supply chain anywhere.

Counterfeit drugs are currently a $28 million industry. Don’t let yourself be a victim. Below are some tips that will help.

1. If you take a medication for a chronic condition – save the packaging from the month before and compare the bottle, packaging or the pill itself.

2. If you only receive the pill in a generic bottle compare a picture of the tablet at www.fda.gov by simply searching for the medication.

3. If you are taking a medication and it just doesn’t feel the same or is not working like it normally does, see your doctor and show the medication to your pharmacist.

4. If the medication is deemed counterfeit, save a sample until you see your doctor to make sure there will be no long term complications or side effects.

Healthcare fraud is everywhere – even in countries that have government run programs. Below are some examples:

Healthcare fraud knows no boundaries. The U.S. Medicare and Medicaid programs are equivalent to many government-sponsored programs in other countries. Regardless of country, the existence and roles of players within the healthcare continuum are the same. All healthcare systems have patients, providers, TPAs (third-party administrators) that process reimbursements to third parties, plan sponsors (usually government programs or private-pay activities) and support vendors.

Examples of international healthcare fraud are plentiful. In France, a psychiatric nursing home took advantage of patients to obtain their property. In 2004, a newspaper in South Africa reported “a man who posed as a homeopathic doctor was this week sentenced to 38 years in jail – the stiffest term ever imposed by a South African court on a person stealing from medical aids.” An Australian psychiatrist claimed more than $1 million by writing fake referrals of patients to himself; he also charged for the time spent having intimate relations with patients.

In Japan, as in the United States, there are examples of hospitals incarcerating patients, falsifying records and inflating numbers of doctors and nurses in facilities for profit. A U.K. medical researcher mislead his peers and the public by using his own urine sample for 12 research subjects. Switzerland, know for its watches, had providers sanctioned for billing 30-hour days.

Excerpt from Healthcare Fraud: Auditing & Detection Guide by Rebecca Busch

Medical Business Associates, Inc. has been chosen as one of the 30 semi-finalists (over 130 companies applied) for Innovate Illinois – a statewide entrepreneurial and innovation competition recognizing high-growth entrepreneurs.

The next round of the competition, taking place September 24th at the University of Illinois Urbana-Champaign, includes a 5-minute pitch followed by a short question and answer session.

Grand prize is $30,000 in grant money. Good luck Rebecca Busch and Medical Business Associates!

Read more about Innovate Illinois.

Medical Business Associates, Inc. provides a much-needed voice for those that find themselves “stuck in,” “lost in” and “hurt by” our healthcare system. In 1991, President & CEO Rebecca Busch formed Medical Business Associates, Inc. with the vision of delivering data-driven audits for patients, employers, healthcare providers, payers and government agencies. Rebecca is a nurse, patient advocate and health care consultant. She is also a patient, mother of three and informed health care consumer. Her work has provided her with a deep and unique understanding of our medical system. It has also provided her exceptional insight into the problems that patients can encounter.

Rebecca and her team take their role as Patient Advocates very seriously. They empower patients to feel more “in control” of their healthcare experience, to feel hopeful about their health and ultimately become conscientious consumers of healthcare. Rebecca and her team help patients manage, control and reduce their healthcare costs, make informed decisions about their healthcare, guard protected health information, control their healthcare information and prevent clinically adverse outcomes. For those patients that do not have the resources to have a Patient Advocate, they can qualify for help via the not-for-profit organization American Health Care Advocacy of which Rebecca is a Director.

Several years ago, Rebecca had the privilege of helping Janet (pseudonym) – a woman who wanted to take charge of her healthcare experience. Janet came to Rebecca because she was worried about the care that she was receiving. When Janet underwent a common surgical procedure, she experienced intra operative awakening, a rare and horrifying condition in which a person under anesthesia can feel, hear and experience a surgery as it is taking place but is unable communicate with the surgeon in anyway. When Janet came to Rebecca to tell her that the surgeon told her that she “must have been dreaming,” Rebecca began to ask questions to find out how and why this could have happened to Janet and whether this supposed dream was in fact a reality. Janet explained to Rebecca that her mother had a similar experience during open-heart bypass surgery and that her daughter recently did not respond to anesthetics at a dentist visit. Rebecca wrote a supplemental report to put into Janet’s medical record and personal health record detailing what she had experienced. Rebecca told Janet to never let any anesthesiologist “touch” her without reading the anesthesia records from this surgery. Several months later, Janet needed surgery again. She gave Rebecca’s report to the anesthesiologist, who was very appreciative for having this information before the surgery. Janet never experienced intra operative awakening again. This is just one of the many people that Rebecca has helped navigate through our complex healthcare system.

Medical Business Associates, Inc. also fights against healthcare fraud, medical identity theft and the “ethically challenged” that steal from our healthcare system everyday. Rebecca and her team have uncovered healthcare schemes that have saved people millions of dollars.

Vote for us here!

In 1927, on the eve of the Great Depression, Baylor Hospital in Dallas entered into an agreement with the local teachers’ union. The agreement involved an employee deduction per paycheck paid in advance to the hospital. In turn, the hospital offered hospital-based care for these teachers and their families. This deduction was determined using a community-based rating model. Eventually, an organization known as Blue Cross emerged and started to provide the same type of program. Note, however, that a model known as prepaid practice groups (PGPs) already existed. Prior to this time period, private insurance did not exist for healthcare services. Health insurance offerings were avoided because appropriate premium rates were too difficult to predict, unlike rates for insurance upon the death of an individual. Private insurance plans started to appear in the late 1930s. These plans, however, were driven by risk-based models. They focused on the experience of the group. Blue Cross now had competition and was losing its customer base because of the new private-payer offerings. Blue Cross shifted toward a modified adjusted community rate plan, eventually abandoning it completely and joining the private-payer risk model plans. Eventually Blue Shield emerged to serve coverage for professional services.

This introduction illustrates one of the very first critical “cost shifting” market movements. What does cost shifting mean? It is when the cost of certain activities is shifted to another party. The question is, to whom? Private payers profited by removing high-risk individuals from their plans – they were growing at a rapid rate because during WWII a wage hold was put into place. Employers started to realize that benefit plans could be seen as a non-wage form of compensation. The tax code encouraged employers to view benefit plans as a cost of doing business, and employees never had to claim their benefits as income.

The benefit plan offering generated a significant amount of cash in the healthcare system. During the 1940s and going forward, teaching hospitals were also recipients of large amounts of cash infusion by the government’s investment in research and technology. The flow of cash from both areas generated a significant offering of healthcare diagnostics and treatment options. By 1946, the healthcare market had increased cash flow for hospital coverage. This resulted in increased utilization of hospital services. The amounts of insurance payments and premium programs went up. Hospitals expanded because of the available cash. The market had a significant buildup of resources. The amount of technology was growing at an accelerated rate. This fueled additional use and sale of insurance. The gap between the haves and have-nots exploded. From 1930 to 1965, there was the first big cost shift of high-risk individuals to uninsured status. Who were these people? They were the elderly, the unemployed, the self-employed, the retired and the disabled. With the aggressive advancements in healthcare, the disproportionate offerings between the haves and the have-nots became obvious.

The political arena debated the concept of compulsory insurance or a nationalized health plan. Instead, in 1965 Medicare was born to serve the have-nots. Medicare takes a social insurance approach, and its members are referred to as beneficiaries. Medicaid was also established; it is managed at the state level. Medicaid, however, uses a welfare approach, and its members are referred to as recipients. The market at the time believed that employer-linked insurance would eventually serve as a form of nationalized health insurance. Medicare Part A was created to pay hospital services, and Medicare Part B was created to serve the professional component. To devise a nationalized healthcare program was not necessary. The market, it was thought, would take care of itself.

Excerpt from Healthcare Fraud Auditing & Detection Guide by Rebecca Busch