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.

The article highlights coding audits and the reasons for them – Rebecca asserts that in order for the Centers for Medicare and Medicaid Services (CMS) to lower its costs, it devised several financial recovery divisions to catch overpayments and fraudulent claims. Some audits include RAC (Recovery Audit Contractor), which evaluates a provider’s claims data, and medical records for possible over/under payments and ZPIC (Zone Program Integrity Contractor), which, according to the article, are the “aggressive cousins of RACs formed by CMS to detect fraudulent claims activity.”

Rebecca goes on to discuss payer fraud and how it will affect health information technology (HIM). HIM departments need to audit yearly to ensure they are not releasing personal health information (PHI) into the hands of fraudsters. As Rebecca states, “For HIM, the ‘year of the audit’ is about ‘releasers beware.’”

Criminals pose as insurers to obtain medical records and other sensitive information more times then one would think. Rebecca says, “This is what makes HIM vulnerable – people who really understand how the department works and how correspondence works. They are writing letters in a typical format that is routine. So it is going to really easy to miss letters that don’t have altruistic intent.”

With 2010 being the year of the audit everyone in the healthcare industry needs to be alert and in top form. The government is looking for overpayments. Insurance companies are looking for overpayments. Hospitals need money to continue to provide services and can’t afford to miscode, bill incorrectly or anything in between. It is a buyer’s beware market out there and patients most likely the ones to be most affected by these audit initiatives.

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.

President Obama, following former President Bush’s initiatives, is pushing for everyone to have an EHR or EMR by 2014 (EHR = Electronic Health Record, EMR = Electronic Medical Record). However the problem with this implementation is that currently, most hospitals do not have adequate safeguards to protect highly private and highly valuable medical information (medical identity information averages $50 per identity; a SSN will net thieves only $1).

In many cases, medical identity theft is committed by individuals with inside access to medical information – doctors, nurses, pharmacists, hospital workers etc. By allowing information to essentially “flow freely” throughout the healthcare marketplace we are opening ourselves up to fraudsters and thieves and making medical identity theft even easier than it was before.

According to the World Privacy Forum, 3% of all identity theft victims in the U.S. or 250,000 Americans reported that their identity had been used fraudulently to obtain medical treatment, services or supplies. The World Privacy Forum asserts that this number will only increase in the future.

While EHR adoption will push our country in the right direction in terms of quality of healthcare, what steps are we taking to prevent our most private information from being stolen and used against us?

The hacker posted on the site’s homepage an expletive filled rant claiming that he was in possession of very confidential data. He continued by writing that if Virginia didn’t follow his ransom demands, he would sell all the information to the highest bidder.

Virginia didn’t succumb to the hacker’s demands; however, their website was not functional for a period of time.

Read full article here.

This alleged breach calls into question the effectiveness and security of EHRs (Electronic Health Records). While EHRs will save an estimated $11 billion annually, skeptics say that patient information will be more vulnerable than ever.

Medical Business Associates, Inc. can consult companies and hospitals on the right way to secure online medical records. Our experts are trained to find holes and teach you the proper way to fill them. Our pre and post EHR implementation audits have saved many organizations from experiencing the headaches associated with EHR implementation.