Medical Business Associates, Inc. Patient Hotline: 877-MBA-UWIN (877-622-8946)
Website
Web
Twitter
Twitter
Mail
Mail
Training Institute
Training
We Understand How Information and Money Move In Healthcare
 
     

Archive for the ‘Medicare Fraud’ Category

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

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

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.

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.

Healthcare Fraud Roundup

Thursday, October 14th, 2010

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.

Top 10 Hospital Stories of 2010

Tuesday, September 14th, 2010

Becker’s Hospital Review recently posted their collection of the top 10 hospital stories of 2010. Many of the topics reflect the major hospital stories of 2010 – a few really delve into the growing problems and concerns for hospitals that are not necessarily on the forefront of discussion.

Here are the top 10 terms/stories for 2010:

1. Healthcare reform
The term “Healthcare reform” was everywhere this year. People are still scratching their heads wondering exactly what that means. 2011 will be a big year along with the next 4 years to see whether healthcare reform will hold up to its hype.

2. Integrating healthcare delivery

3. RACS get rolling

With RACs in full swing, hospitals are developing ways to ensure they meet standards. In the first quarter of 2010, RACs denied a total of $2.47 million in Medicare claims, according to the AHA’s RACTrac Survey of 653 hospitals. In 2011, it will be increasingly important for hospitals to be aware of these audits.

4. For-profits buy up hospitals

5. Ban on physician-owned hospitals

6. Physician fee cuts
With Medicare fees cut by over 20%, some physicians are losing faith in the system. What will this mean for the future of Medicare and physicians and hospitals accepting Medicare? The next 2 years will be key for this.

7. Hospital quality reporting

8. The war against healthcare fraud
One of our favorite topics, the war on healthcare fraud, waste and abuse is continually growing and ever-present. While Congress realizes that there is a need to combat this abuse, we haven’t successfully implemented initiatives to thwart it substantially. The healthcare reform law provides $300 million in funding for fraud investigation and enforcement by over the next 10 years. It will be up to Congress to ensure this money is spent wisely, efficiently and effectively.

9. Big boost for healthcare IT
EHRs, EMRs, Personal Health Records – what does all this mean for Health-IT and e-health? Lots – especially with government investing, beginning in 2011 and lasting for the next six years, $34 billion in incentives for healthcare IT to hospitals and practices.

10. Don Berwick arrives at CMS

Healthcare fraud: How it affects the consumer

Monday, May 10th, 2010

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.

Schemes to defraud the health system

Wednesday, February 24th, 2010

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.

Healthcare Fraud Examples

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.

Healthcare Fraud in International Markets

Saturday, October 17th, 2009

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