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

Archive for the ‘Pharma 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.

Pill Mills: New Laws, New Offenders, Same Old Scheming

Thursday, June 2nd, 2011

What is a Pill Mill?

A Pill Mill consists of a doctor, clinic or pharmacy that is prescribing or dispensing powerful narcotics inappropriately or for non-medical reasons.

How do pill mills work?

  • Only accepts cash
  • Pain is the only illness “treated”
  • No physical exam is needed
  • Pain is only treated will pills, no other methods are examined

New Laws

Rules in Pill Mill hotbeds of Florida and Ohio have recently been put into place to stop these schemes. In Ohio a bill passed that will enhance “reporting requirements for physicians who also furnish drugs, establish a clearer definition of “pain management clinic,” and require the state Medical Board to develop standards for operating such clinics.”

The bill also mandates that Medicare and Medicaid systems be better managed to weed out individuals who are getting the prescription medications and then selling them.

In Florida, lawmakers have made more requirements for doctors looking to operate pain management clinics. The law will also impose new administrative and criminal penalties for doctors who overprescribe narcotics.

Recent Crackdowns

A February raid of 11 pain clinics from Miami to West Palm Beach lead to the arrests of 23 people, including four physicians, and seized $2.5 million in cash and dozens of cars.

Something good to come from these recent raids – Oxycodone pills are harder to find in street deals nowadays, evidenced by the rise in prices from around $5 per pill to $20.

Cracking down on prescription drug abuse will hopefully lead to fewer prescription drug related deaths.

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

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

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.

Tips for Protecting Yourself from Healthcare Fraud

Thursday, October 14th, 2010

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.

Rebecca’s Health Care 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.

Counterfeit drugs and their effect on health & healthcare

Tuesday, August 17th, 2010

Counterfeit drugs are killing or greatly harming patients that are desperate for medical care. Estimates state that nearly 700,000 people are killed each year after ingesting counterfeit malaria and tuberculosis drugs.

The World Health Organization (WHO) estimates that up to 30% of medication on the market in developing countries in Africa are counterfeit and have found that nearly 50% of the drugs sold in Angola, Burundi, and the Congo are of poor quality. Furthermore, nearly two-thirds of anti-malaria drugs in Laos, Myanmar, Cambodia, and Vietnam contain insufficient active ingredients.

A 2003 Interpol survey on the quality of drugs available in Lagos, sub-Saharan Africa’s most populous city concluded that 80% of the drugs available were fakes. In 2008, more than 80 children in Nigeria died after being given medicine that looked, smelled, and tasted like the real thing, but was laced with antifreeze.

Why are the numbers so high? Jacqueline Sawyer, Liaison Officer at WHO’s Prequalification of Medicines Programme, told MediaGlobal “The problem of counterfeit medicines is more prevalent in countries where medicine regulation is ineffective, smuggling of medicines is rampant, secret manufacturing exists, sanctions are absent or very weak, and there is high corruption.”

Do not think counterfeit or tampered drugs only exist in developing countries. An estimated 1% of all medicines dispensed in developed countries are counterfeit. Medicines containing boric acid and other lethal substances have been found recently in certain medications.

To be sure that your drug is safe to use, check the FDA’s website. They announce drugs that might have been tampered with and also have correct packaging and dosage information.
Recent FDA Headlines:
FDA Warns About Fraudulent Tamiflu
Warning: Counterfeit Alli
FDA Issues Warning on Counterfeit Surgical Mesh

Full article here.
FDA here.

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.

Prescription fraud and misuse rising

Saturday, January 30th, 2010

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 abuse:
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 the types of abuse 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.