Some stats for thought:

• As many as 500,000 Americans have been victims of medical identify theft, according to the World Privacy Forum.
• At one medical clinic in Weston, Florida, a front desk clerk downloaded information of more than 1,100 Medicare patients and gave it to a cousin who made $2.8 million in false Medicare claims.
• Thieves use your identity to buy prescription drugs. They then sell these prescriptions or use them to feed their own addictions.

What does this mean to the average person?

If you find yourself being a victim of medical identity theft, you might receive hospital bills in the mail for services you never received. You might visit an area hospital only to find your records include false or wrong information, like blood type or previous surgeries you’ve never received. You could even have your kids taken away like this unassuming woman almost did during her ordeal with medical identity theft.

“Anndorie Sachs, a mother of four from Salt Lake City, has always considered herself a loving, caring mom.  So one can imagine her surprise when a state social worker called Sachs and accused her of having given birth to a baby girl with methamphetamines in her system and abandoning her in the hospital.

Even more unthinkable, according to Sachs, the state told her over the phone she was an unfit mother, and planned to take custody of all her kids.  “I definitely went into shock,” she says.  But, Sachs hadn’t given birth to a baby with meth in its system. In fact, she hadn’t given birth in two years.  Anndorie Sachs was a victim of medical identity theft.”

How can you avoid becoming a victim?

If you don’t monitor your EOBs fraudsters have a better chance of stealing your Medical Identity. This can cause both financial and physical harm – if someone else’s information is included in your medical record you could receive false diagnoses. Take ownership of your healthcare finances and request your medical records and bills once a year.

If your wallet is stolen, notify your insurance company — not just credit-card companies — because your benefit card is like a credit card without a limit.

Be an empowered patient and take charge of your health and healthcare finances.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Medicare fraud is hitting Chicago – hard. Chicago’s vulnerable population of senior citizens is receiving the brunt of the fraud, with the unethically targeting nursing homes and elderly living communities. A recent scheme involving elderly immigrants and durable medical equipment was snuffed out by authorities, but not before the fraudsters stole Medicare ID numbers.

Other recent Chicago healthcare fraud schemes include:

Dr. Jaswinder Rai Chhibber, owner of Chicago’s Cottage Grove Community Medical Clinic – charged with ordering unnecessary diagnostic tests for seniors and other patients in an effort to boost revenues from Medicare and Medicaid. Tests included echocardiograms, electrocardiograms and lung function tests, among others.

Marilyn Maravilla, a Chicago nurse, and four others were charged in a criminal complaint with paying kickbacks to various health care providers in exchange for referrals to her agency, Goodwill Home Healthcare Inc. of Lincolnwood. This fraud is part of a bigger, $200 billion scheme brought down by the HEAT taskforce.

Virgilio Orillo and Merigrace Orillo, owners of Chicago’s Chalice Home Healthcare Services Inc., were charged in a criminal indictment with falsifying documents in an effort to boost Medicare payments. The alleged scam, according to the government: Patients were listed as being homebound and in need of skilled assistance when it wasn’t true. (Medicare pays for home health care only for patients who meet these criteria.)

Thanks for reading!

Your healthcare resource – Rebecca Busch

A HealthGrades report indicates that there have been between 400,000-1.2 million error-induced deaths during 1996–2006 in the United States. On top of that, $60 to $80 billion is lost each year in the healthcare system due to fraud, waste, and abuse. How can you protect yourself from these alarming numbers?

As a patient you have many resources at your fingertips. Before you even visit a healthcare facility or provider, perform a due diligence check on both the facility and the provider.

First, confirm your physician’s NPI number – all physicians are required to have a NPI number for Medicare billing. Even if a physician is not billing Medicare, they need to have a NPI number to refer patients to other physicians.

Here is a free site to find your physician’s and facilities’ (where you will be receiving the treatment) NPI number.

Second, authenticate your physician’s and facilities’ information with the NPI registry. Here you will be able to confirm the provider’s legal business name and/or location, contact information, and NPI number. The NPI Registry is a free service located here.

Third, research the background history of your provider to see whether he/she has been disciplined, fined, or has had a suspended license. The State of Illinois License Lookup allows you to confirm all licenses distributed by the State of Illinois including MD, RN, PharmD, DO, etc.

Finally, a simple Internet search on the provider/facility may garner surprising results. Oftentimes, pending lawsuits and court filings appear at the top of Internet searches if the provider/facility is involved.

If you suspect anything, remember to request a copy of your medical records and billing statements. By performing your own mini-investigation you will be able to determine if your provider is supplementing or omitting information from your medical records or billing statements.

Useful sites:

NPI Registry

NPI Number Lookup

State of Illinois License Lookup

And cue… “Bad boys, bad boys, whatcha gonna do, whatcha gonna do when they come for you?”

The Office of Inspector General (OIG) of the Department of Health & Human Services launched a Most Wanted Fugitives List for those criminals wanted by authorities on charges of healthcare fraud and abuse. This most wanted list is a tool to bring attention to the fugitives and their crimes against the healthcare system.

The list on the OIG website includes photos, profiles, and a list of crimes of each featured fugitive. The 10 individuals on the list have allegedly cost taxpayers more than $124 million in fraud. In all, OIG is seeking more than 170 fugitives on charges related to healthcare fraud and abuse.

Included on the Most Wanted Fugitives List:

1. Eduardo Moreno

Moreno allegedly stole hundreds of thousands of dollars from the Medicare program, submitting false and fraudulent claims for durable medical equipment (DME) “and related health care benefits, items and services” that were medically unnecessary.

Moreno was a sneaky fraudster, using a “straw owner” and other methods to hide the money and property he obtained. (A straw owner is an individual who maintains the appearance of owning property in order to disguise the identity of the real owner.)

2. Leonard Nwafor

Nwafor billed Medicare for $1.1 million and collected $525,000 in fraudulent claims for such durable medical equipment (DME) as motorized wheelchairs, scooters, and hospital beds for beneficiaries. This investigation was led by the Medicare Fraud Strike Force, including OIG investigators, which was created to identify and prosecute fraudulent DME companies and laboratories in the Greater Los Angeles area.

The website also provides you with the opportunity to report any of the fugitives or any other individuals believed to have committed healthcare fraud. The site also includes a toll free number.

Take a look at the fugitives and spread the word! These are the individuals causing healthcare costs to increase and benefits to decrease.

On Wednesday, Rebecca participated in a Webinar for an Illinois Workers’ Compensation Association. She presented on the topic “Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting.” In front of an audience of case managers, attorneys, human resource personnel and other healthcare professionals, Rebecca had a lively discussion on many aspects of healthcare fraud in a Workers’ Compensation setting.

Some highlights include:
Overall numbers –
The Insurance Information Institute estimates that all property/casualty insurance fraud cost insurers $30 billion annually.

Workers’ Compensation fraud accounts for approximately 25% or $7.2 billion a year, according to the National Insurance Crime Bureau (NICB).

The NICB characterizes Workers’ Compensation fraud as the “fastest growing segment of insurance fraud” in the nation.

Most studies indicate that the three parties primarily driving the cost of workers’ comp fraud are employers, medical providers, and employees.

Tips on spotting fraud:
Worker Claim Fraud
• Number of days worked and amount of salary inconsistent with occupation
• Injured worker disputes average weekly wage due to additional income (i.e., per diem and/or 1099 income)
• Cross-outs, white-outs and erasures on documents
• Injured worker files for benefits in a state other than principle location of the alleged industrial injury or occupational disease
• Injured worker-listed occupation is inconsistent with employer’s stated business
Employer Fraud
• Business displays or presents a Certificate of Coverage that contains inaccurate data, such as an implausible period of coverage
• Cross-outs, white-outs and/or erasures on documents, such as the Application for Ohio Workers’ Compensation Coverage (U-3) or Payroll Report (DP-21)
• Business name is not consistent with type of work being performed
• Number of employees, classifications and payroll are inconsistent
Provider Fraud
• Injured worker does not recall having received the billed service
• Provider’s medical reports read almost identically even though they are for different patients with different conditions
• Much higher healthcare costs than expected for the allowed injury type
• Frequency of treatments or duration of treatment period is greater than expected for allowed injury type, especially for older (non-catastrophic) claims

When investigating workers’ compensation fraud, always request detailed medical records and records of the injury. If all the facts don’t add up – you might be looking at fraudulent activity.

What are the fraudsters doing these days? Well, according to reports, NOT getting away with healthcare fraud. The government is in hot pursuit of those that are bilking the system.

Some recent arrests include:

A Michigan podiatrist was accused of filing more than $800,000 in fraudulent claims. The doctor billed insurance providers for surgical procedures performed after falsely diagnosing patients with foot infections.

A New York surgeon was charged with stealing $3.5 million from insurance companies. The Department of Health & Human Services also investigated his billing patterns and found he had allegedly billed for multiple hemorrhoidectomies, office visits and examinations on the same day for the same patient on multiple occasions.

A Chicago-area cardiologist was ordered to pay $20 million and sentenced to 5 years in prison for defrauding both private and public insurers. The whistle blower on the case was another physician who worked in the same office.

Two West Virginia internists were sentenced to one year and one day of prison time after admitting to their involvement in a pill mill scheme. The local pharmacy where the prescriptions were sent by the physicians sold more hydrocodone in 2006 than all but 21 retail pharmacies in the country.

A California pathologist was sentenced to 25 years in prison for prescription fraud. He wrote fraudulent prescriptions for oxycodone in exchange for cash. In some cases the prescriptions were for minors under the age of 21.

In Miami a massage clinic owner was convicted of Medicare fraud. The owner was charged with submitting false claims for physical therapy services that were never given and occupational therapy services that Medicare does not cover.

Healthcare fraud is prevalent, but we’re finding ways to stop the bad guys.

Rebecca Busch’s healthcare tips were recently featured on EmpowHER a health and wellness site for women.

EmpowHER brings together women of all backgrounds to share their health stories, triumphs and tragedies. For Rebecca’s part, she spoke on what she knows best, healthcare fraud.

Below are her tips:

1. Counterfeit Drugs
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. Double Billing
Look at your Explanation of Benefits (EOB) after each doctor’s visit. Ask yourself, “Did I actually see that doctor or receive those services?” If the answer is no, call your insurer immediately.
3. Medical Identity Theft
If you don’t monitor your EOBs fraudsters have a better chance of stealing your Medical Identity. This can cause both financial and physical harm – if someone else’s information is included in your medical record you could receive false diagnoses. Take ownership of your healthcare finances and request your medical records and bills once a year.
4. Medication Delivery Errors
Deaths occur each year because patients are given prescriptions at the wrong time, in the wrong dose and of the wrong medications. Make sure you understand your medication regime and that the hospital staff is adhering to it.
5. Phantom Treatments
Some healthcare criminals bill insurance companies for services never received by patients. If you receive a bill that doesn’t make sense, contact the provider or your insurer.
6. Invalid Licenses
Some doctors practice without a valid license. To verify a license, find the Department of Regulation for your state and look up your provider’s name. Here, you can also see if they have ever had a disciplinary action against them.
7. Fake Insurance
Dishonest insurance agents and brokers sell discount cards and insurance cards for fake policies. Any health insurance plans that are priced below industry norms are likely fake. Remember, if it seems too good to be true, it is.
8. Prescription Mix-Ups
Medication errors occur more than you think – a hospital on the East Cost mixed up medication in roughly 1 in 8 prescriptions filled. Take an active role in your care and check your pills to ensure you have been given the drug you were prescribed.
9. Bad & Low Quality Care
Unqualified and untrained surgeons perform surgeries. Doctors use defective medical equipment to perform exams. Check the reputations of your doctors and facilities. Look for complaints lodged against them.

Information Security Media Group – a media company specializing entirely on information technology risk management for vertical industries, recently interviewed Medical Business Associates, Inc. President & CEO Rebecca Busch for her thoughts and commentary for a podcast “Cracking Down on Insurance Fraud.”

Rebecca highlighted the fact that a good foundation based on fraud risk assessments needs to be established to fight fraud. She also points out that insurers and providers need to regularly audit all network activity to assess risk and potential vulnerabilities where holes might be found.

Her opinion on Healthcare Reform – it might lead to an increase in insurance fraud in the short term as information systems are adjusted and new rules are implemented but should eventually decrease fraud, as more individuals will receive health coverage.

Roughly 60 billion healthcare dollars are lost each year due to fraud, waste and abuse. How does this theft affect you the taxpayer and healthcare consumer?

The answer is surprisingly simply ­ it hits your wallet first. Insurance premiums are increasing at a staggering rate ­ 33% in the last five years. If this continues, most individuals will not be able to afford any type of insurance, costing taxpayers even more because they will be the ones footing the bill for the uninsured.

Insurance premium increases hit the employer even harder. Many times employers (especially small businesses) are forced to reduce their workforce to accommodate the rising costs or even cut healthcare benefits entirely.

Prescription drugs are an area that is greatly affected by fraud. Fraudsters are fans of selling counterfeit medication. Consumers ingesting this medication (many times laced with poison ­boric acid for example) can end up in the emergency room with complications costing thousands.

The recent passage of Healthcare Reform is also proving to be good news for fraudsters. Many consumers have little to no knowledge of the bill and scammers have found multiple ways to cheat the innocent out of their money.

Fraudsters prey on the fear and confusion brought about by the bill. Going door-to-door selling fake insurance, scammers advertise an “ObamaCare” plan and insisting consumers better act fast due to a “limited enrollment” period. These scams bilk consumers out of thousands of dollars and leave them without any real insurance, so if a medical emergency where to occur, they would be left footing the bill.

So, what can the consumer do to help combat healthcare fraud? First, understand exactly what you’re being charged for and always ask for clarification on any charges for services that you do not recognize. Second, know where your medical identification is and alert proper authorities when your insurance card has been stolen ­ medical identity theft crimes can leave you sorting out medical bills for the rest of your life. Finally, be a conscientious healthcare consumer. Be aware of current fraud schemes and check out the Food & Drug Administration website to ensure your medication is not on the counterfeit list.

We have discussed types of healthcare fraud (i.e. Rent-a-Patient Schemes, Pill Mill Schemes, Drop Box Schemes & Third-Party Billing Schemes) in a previous post. However we didn’t highlight some new ways scammers and fraudsters are stealing your healthcare dollars, mainly through the online world.

A recent ABC News article, “Health Care Fraud: Two Ways Scammers Are Trying to Take Your Money” describes two “ingenious” ways fraudsters are stealing your money. The article explains that because of all the healthcare hoopla occurring, people do not understand and are unaware of current policies – leaving what they call “anxious Americans.” This is how the scammers get you.

The first scam that was highlighted was “Door-to-door salesman selling bogus policies.” What does that entail? Scammers are going door-to-door selling fake insurance policies by stating that current legislation is accounting for the low “limited enrollment” period fees. They are confusing people by essentially telling them that if they don’t buy the insurance now, the price will increase excrementally and they will not be able to afford it in time.

The next scam “1-800 advertisements promoting scams” is very similar to the door-to-door scam; however, this time the fraudster are taking it to the airwaves and asking people to call and 1-800 number for “limited enrollment specials made possible by new legislation.”

As always, don’t forget about Medical Identity Theft – this practice is increasing by 375%. The key to any insurance deal is if it is too good to be true than it probably is.