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Archive for the ‘Healthcare Fraud’ Category

A Look into Online Pharmacies

Thursday, November 10th, 2011

When someone says “online pharmacy,” what do you think? Discounted drugs, no need for a prescription, illegal activity… counterfeit or adulterated medications?

Online pharmacies tend to fall into the illegal activity and counterfeit medication categories. While there are some legal and legitimate online pharmacies out there (more on that in a minute), you need to be aware that more and more online shops are popping up selling expensive medications at better than wholesale prices.

Due to the fact that counterfeit versions of at least 40 of its drugs have been found in more than 100 countries, drug maker Pfizer and a national pharmacy standards group started a website warning consumers about counterfeit prescription drugs and explaining how to find legitimate online pharmacies.

One way to weed out the bad online pharmacies is to look at their prices. If they are too good to be true – they are. For instance, Pfizer’s drug Viagra typically is sold to distributors for around $18 per tablet. One online pharmacy sells 25mg tablets for between $1.09 to $2.49, and another list 130mg tablets from 99 cents to $1.31 per pill. How can they sell an $18 per pill drug for as little as one dollar? Where is the profit in that?

Scope of the Problem

While it is very difficult to measure how much illegal pharmacies are making from selling counterfeit medications, a case was recently in the spotlight concerning these online pharmacies. In August 2011, the U.S. Department of Justice demanded Google to forfeit $500 million in revenue generated by online ads for online pharmacies. $500 million on advertising is a big chunk of change – if these pharmacies can afford that, this business model is obviously lucrative.

Legitimate Online Pharmacies?

The controversy exits with online pharmacies. I am sure you have people (including your physicians) telling you not to purchase medications over the internet. However, there are legitimate safe online pharmacies. How can you find them? The National Association of Boards of Pharmacy (NABP) developed the VIPPS accreditation program, which evaluates Internet pharmacy practice. A VIPPS accreditation verifies that the online pharmacy is a virtual equivalent to a brick and mortar shop down the street. But please, keep a watchful with online pharmacies – it should be noted that there are only 29 online pharmacies holding VIPPS accreditation.

Don’t Want to Be Duped?

Now you are thinking, “How can I protect myself from these online predators?” First of all, the easiest way is to avoid online pharmacies. However, there may be some instances where you cannot avoid it. What should you do then?

  1. Buy drugs only from trusted retailers (VIPPS accreditation) and stay away from non-regulated online pharmacies.
  2. If traveling abroad, please bring medications with you and avoid purchasing from countries with a high counterfeit mix (most notably African countries).
  3. The easiest and most resourceful way to avoid counterfeit products is to education yourself on the medications you take. An informed consumer is an empowered consumer. If the drug isn’t acting how it was when you took last month’s supply, it could be counterfeit. If the bottle looks tampered with, check with your pharmacist.
  4. If you have any questions or are worried about your medication, talk with your pharmacist about any recent counterfeit products or check the FDA or drug manufacturer’s website.

To Be or Not to Be (a Whistle Blower) that Is the Question

Thursday, July 7th, 2011

A follow up blog to a post concerning a nurse who was jailed and fined for reporting a doctor… It looks like justice was served in the end.

An Unfair Complaint

A Texas nurse is waiting to stand trial. For what you might ask… Illegal prescription use? Theft? Wrongful death? How about none of the above? Anne Mitchell is facing trial because she is a whistle blower and the doctor in question protested to the sheriff in the small Texas town that he was being harassed and defamed for no reason.

Mitchell wrote an anonymous letter complaining about Dr. Arafiles practices and “mishaps” – including a failed skin graft performed without surgical privileges, suturing a rubber tip to a patient’s crushed finger for protection and a large affinity to herbal supplements which he sold as a side business – to the medical board.

This “anonymous” letter was brought to the attention of Dr. Arafiles who immediately filed a complaint to his friend the sheriff who then issued a search warrant to seize the nurse’s computer and found the letter.

Mitchell had worked for the hospital system for over 20 years. She is a much respected member of the nursing community. She loved her job and only wanted the best for patients. She was doing what every nurse should do – report wrongdoing and highly questionable (on numerous occasions) practices performed by Dr. Arafiles.

Mitchell was charged of misuse of official information, a third-degree felony punishable by prison time and was also fired from her job at the hospital.

A Just Outcome

A jury found Mitchell not guilty. Karma also reared her ugly head, with Dr. Arafiles, the sheriff, and a hospital administrator faced criminal charges in connection with the prosecution and with the firing of Mitchell. The defendants agreed to pay Mitchell and another nurse who was fired as well $375,000 a piece for the wrongful firing.

The state medical board also charged Dr. Arafiles with poor medical judgment, nontherapeutic prescribing, failure to maintain adequate records, overbilling, witness intimidation, and other violations.

Following Dr. Arafiles’ hearing, the board gave the doctor the choice of 2 remedial education programs for physicians along with 8 hours of continuing medication education in medical record-keeping and another 8 hours in evaluating and treating thyroid disease. He has also been put on probation for 4 years and fined $5,000.

Final Lesson

Putting whistle blowers in prison would seem to be a deterrent to those in the future that witness wrongdoing. While there are certainly those that “blow their whistle” in hopes to receiving a grand payday, there are also concerned individuals that do the right thing and report the wrongdoings and injustices they witness.

We have laws in place to protect whistle blowers from retaliation. These laws are necessary to protect individuals who do the right thing and are not afraid of being call “tattletales.”

The whole point of protecting whistle blowers is to give people an incentive to report. Without an incentive we can expect fraud, theft etc. to only increase in the healthcare system.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Protect Yourself from Counterfeit Products and Medications

Tuesday, April 26th, 2011

Johnson & Johnson recently discovered fake diabetes test strips in India – these strips were found in their ongoing worldwide effort to eradicate counterfeit and tampered products.

Johnson & Johnson suspects the strips were made in China and repackaged in counterfeit packaging in India (a whole production).

The good news for American consumers is that Johnson & Johnson has seen no evidence of fake OneTouch strips in the U.S. over the past three years; however, counterfeits continue to periodically crop up in other countries, including Egypt last year and Pakistan in 2009.

How can you, as a consumer, protect yourself from tampered products and medications?
The U.S. Department of Health & Human Services and the FDA provide great resources for consumers.

Some of their tips include:

  • Read the label. Be alert to the tamper-evident features on the package before you open it. These features are described on the label.
  • Inspect the outer packaging for signs of tampering before you buy a product.
  • Examine the medicine itself before taking it. Check for capsules or tablets that differ from the others that are enclosed. Do not use medicine from packages with tears, cuts, or other imperfections.
  • Never take medicine in the dark.
  • Examine the label and the medicine every time you take it or give it to someone else.
  • Tell somebody if the product doesn’t look right. Do not buy or use medicine that looks suspicious. Always tell the store manager about questionable products so that they can be removed.
  • Before buying any medicine, you should stop and take a look. Before taking it, you should look again.

Ensuring Safe Use of Medicine

Thanks for reading!

Your healthcare resource – Rebecca Busch

Chicago – New Healthcare Fraud Hot Bed?

Tuesday, April 19th, 2011

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

Counterfeit Drug Update

Tuesday, April 12th, 2011

Text messages to combat counterfeit drugs:

In Africa, counterfeit drugs are a growing health concern. Some estimates say that nearly 50% of the drug supply is counterfeit. What is one way to combat this growing epidemic? Text messages. That’s right, African’s can submit a verification code hidden in the medicines packaging and submit it to a service to verify whether it is authentic. This pedigree system puts the power back into patient’s hands.

Medicine supply chain breach – worst ever

A British man was found guilty and sentenced to eight years for his involvement in a scheme known as Operation Singapore, which centered on the importation of more than two million doses of counterfeit life-saving medicines into the country.

More than half of these were captured by the Medicines and Healthcare products Regulatory Agency, but a huge amount – almost 900,000 doses – initially reached pharmacies and patients.

Despite an immediate recall of the drugs Zyprexa (olanzapine), Plavix (clopidogrel) and, Casodex (bicalutamide), 700,000 doses were left unaccounted for, putting the health of consumers in jeopardy.

Fake drugs are threatening public health

Consumers look to the FDA and the National Agency for Food, Drug Administration and Control (NAFDAC) to prevent counterfeit drugs from breaching the system. What strong holds are they putting into place to combat this growing problem?

“Recent developments have revealed that only a cross-functional and integrated approach can be successful in defeating counterfeiting and fraud as well as the diversion of pharmaceutical products. That is why the use of these anti-counterfeiting technologies should be embraced extensively by consumers of pharmaceuticals products and pharmaceutical companies should equally employ security technologies in packaging, primarily to support product authentication, provide an indication of a drug purity and allow supply chain to be tracked.”

To read more about new initiatives visit here.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Avoiding Fraud, Medical, and Billing Errors in the Healthcare Arena

Monday, March 21st, 2011

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.

How to Research a Doctor

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

Most Wanted Healthcare Fugitive List

Wednesday, February 9th, 2011

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.

Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting

Friday, December 10th, 2010

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.

The Price of Medical Errors

Tuesday, November 30th, 2010

A recent report highlighted that more than 13 % of Medicare patients in the U.S. experience an adverse event each month in American hospitals – resulting in 15,000 deaths.

AOL Health’s recent article states, “The news is startling, particularly since the report points out that 44 % of adverse incidents occurring in hospitals are avoidable. And all-together, these adverse events are costing Medicare more than $300 million a month.”

Now what are some types of medical errors that have occurred?
1. A doctor operated on and amputated the wrong leg of a veteran.

2. An elderly woman received the wrong blood type during a blood transfusion.

3. A CT scan being performed on a pregnant woman who had a similar name to a patient who was having abdominal pain resulting in harm to the unborn baby.

Link to other, unforgivable medical errors.

Fighting Healthcare Fraud

Friday, November 19th, 2010

All puns aside, the government is really turning up the HEAT on healthcare fraud. HEAT (Health Care Fraud Prevention and Enforcement Action Team) was established in May 2009 to crack down and prevent fraud, waste and abuse in a healthcare system that loses an estimated $60 to $80 billion per year to fraudsters and the “ethically challenged.”

HEAT compliments the joint DOJ-HHS Medicare Fraud Strike Force which is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud using high-tech data analytic techniques and a focus on community policing. Strike Force teams are currently in Miami, Los Angeles, Detroit, Houston, Brooklyn, Tampa and Baton Rouge.

The HEAT task force is comprised of top-level law enforcement agents, prosecutors and staff from both the Department of Justice and the Department Health and Human Services.

How is HEAT weathering the storm? By all accounts, this new task force is living up to the hype. Thirty-six people in five different states have been arrested and 94 indicted following an investigation regarding a Medicare insurance scam totaling over $250 million. Investigators apprehended nurses, doctors and other health professionals in Miami, New York, Detroit, Houston and Baton Rouge.

Attorney General Eric Holder was quoted saying, “With [these] arrests, we’re putting would-be criminals on notice: Healthcare fraud is no longer a safe bet.”

What are the fraudsters doing these days? Well, according to reports, NOT getting away with healthcare fraud thanks to the new task force. The government is in hot pursuit of those that are bilking the system.
As an investigator, here are some sure fire tips to help spot fraud in a healthcare setting:

1. Make sure you have a system in process to collect diagnosis and procedure information.
2. Track diagnosis and procedures provided, even if just by volume.
3. By simply having the right information in a single source data base, we can begin to ask the data, “Where is the hanging fruit activity?” For example, how many procedures are done in one day by one provider? How long does a patient wait to be seen? How far apart are the actual treatments?
4. Finally, tracking the different types of healthcare fraud schemes is just as valuable. A common scheme in many countries is falsifying mental and emotional states of an individual as a ruse to steal assets which lead to misrepresenting identity to receive healthcare services.

Regardless, one thing for sure is that we can always depend on the creativity of the ethically challenged.