Medical Business Associates President & CEO Rebecca Busch was featured in the March issue of the Journal of AHIMA in an article titled, “The Year of the Audit.”

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.

We all know that healthcare fraud is a growing concern. Private (e.g. Blue Cross Blue Shield, Aetna etc.) and public insurers (e.g. the government – Medicare and Medicaid) are both susceptible to fraud with the latter receiving the biggest hit. We know that fraudsters steal money – but how do they do it? In an article released by the United States General Accounting Office (GAO) they highlight some of the major and most prominent healthcare fraud schemes.

1. Rent-a-Patient Scheme
In this scheme organizations pay for—or “rent”—individuals to go to clinics for unnecessary diagnostic tests and cursory examinations. The scary thing is that licensed physicians sometimes participate in the rent-a-patient scheme. Case and point: Robert Bourseau, 75, was sentenced to 37 months in prison and ordered to pay $4.1 million in restitution for his role in a scheme to defraud Medicare and Medi-Cal. He pleaded guilty in June to paying a recruiter to deliver homeless patients to his hospital for unnecessary medical services.

2. Pill Mill Scheme
In this scheme, separate health care individuals and entities (usually including a pharmacy) collude to generate a flood of fraudulent claims that Medicaid pays. After a prescription is filled, the beneficiary sells the medication to pill buyers on the street who then sell the drugs back to the pharmacy. Example: Rick Kloxin, pharmacist in charge of Hogan’s Pharmacy in Lyons, Kans., was found guilty in an internet pill mill scheme. Kloxin pled no contest and was found guilty of 14 misdemeanor counts of violating Kansas Pharmacy laws.

3. Drop Box Scheme
This scheme uses a private mailbox facility as the fraudulent health care entity’s address, with the entity’s “suite” number actually being its mailbox number. The fraudulent health care entity then uses the address to submit fraudulent Medicare, Medicaid, and other insurance claims and to receive insurance checks.

4. Third-Party Billing Scheme
The third-party billing scheme revolves around a third-party biller—who may or may not be part of the scheme—who prepares and remits claims to Medicare or Medicaid (electronically or by paper) for health care providers. It is possible, however, for a third-party biller to defraud Medicare, Medicaid, and others by adding claims without the providers’ knowledge and keeping the remittances or by allowing fraudulent claims to be billed to Medicare or Medicaid through its service. Example: Recently, in Miami, Ihosvany Marquez and several alleged conspirators were indicted on charges of having filed $55 million in phony Medicare claims for HIV, AIDS, cancer, pain and varicose vein treatments.

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.

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!

It would seem that having all your medical/health information in one place would be a good thing. You wouldn’t have to go from doctor to doctor requesting medical charts and cutting through red tape to access your “private” files. However, we all know from experience that the Internet is not always the safest place to store information – identity theft is running rampant throughout the country with thieves stealing your information right off of your personal computer.

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?

See Rebecca Busch’s expertise quoted on the Examiner. Just a little teaser – healthcare fraud costs us an exorbitant amount of money.

Read full article here.

Doctors Community Hospital was fined $30,000 for violating a law that says all Maryland hospitals must report serious medical errors. The penalty was set at $95,000, but Doctors Community Hospital promised to set aside $65,000 to develop a safety program for patients.

Some of the unreported errors include: A patient being attacked by another patient’s visitor, an 8-day delay on IV medication for a man known to have heart failure, and a case where an antibiotic was mistakenly given to a patient after a technician thought it was plain IV fluid.

Read full article here.

This should be a warning to patients and healthcare providers. Hospitals should be required to report serious medical errors because patients have the right to know what sort of medical care they will receive at any given hospital. Medical Business Associates, Inc. recommends that patients take charge of their own healthcare and well being by developing and maintaining a Personal Healthcare Portfolio.