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Archive for the ‘U.S. Government’ 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.

CommunityHealth – Illinois Largest FREE Health Clinic

Friday, November 4th, 2011

I would like to introduce an organization that is extremely important to the Chicago community – CommunityHealth. I support CommunityHealth and its mission as a board member, contributions in kind, and direct cash donations.

Healthcare is expensive and costly. I can tell you from personal experience that many individuals go without badly needed primary care services as a result of the expense.

On that note, I have had the privilege of working for a great organization – CommunityHealth – which provides free healthcare services to the underserved and uninsured. If you have 2 minutes, I would appreciate you watching this short video explaining just how important CommunityHealth is to the community, and what you can do to help.

Donate to Chicago Community Health

To all my clients, friends, and loyal readers, if you take the time to donate $500, I provide you with a free copy of my healthcare advocacy book – Personal Healthcare Portfolio: Your Personal Health & Wellness Record (a $20 value). If you donate $1,000 you will receive a copy of all three of my books (PHP, Healthcare Fraud: Audit & Detection Guide, and Electronic Health Records: Auditing & Detecting – a $130 value).

To donate to CommunityHealth please click here. Remember, unlike other organizations who have large overhead costs, $.97 of every $1 donated goes directly to patients in need. Your money matters.

Submitting Bills into Evidence

Wednesday, July 20th, 2011

In Illinois in order to submit medical bills into evidence at trial, an opinion is typically required to show that the medical services and charges were usual, customary, and reasonable. An earlier case is often cited Arthur v. Catour, 216 Ill.2d 72 that “to introduce an unpaid bill into evidence, a party must establish that the bill is reasonable for the services of the nature provided.”

Citing a more recent Illinois case, the plaintiff (citing Betty Kunz v. Little Company of Mary Hospital and Health Care Centers, et al., Nos. 1-06-1707 & 1-06-1814) “can establish reasonableness by introducing the testimony of a person having knowledge of the services rendered and the usual and customary charges for such services.”

The skill sets required for this type of analysis include understanding the environment of the services rendered, in addition to healthcare reimbursement.  The method for how healthcare is paid for is complex and layered with components such as understanding ICD (diagnosis codes) and CPT codes (procedure codes). You also have to look at how these services are rendered in the provider environment.  The generation of a provider bill is a multi-layered process. If you have one party that does not stipulate to the bills, then it becomes important to have those bills reviewed by qualified medical auditors.

The following provide some helpful hints of the information you should request:

1.       Provider request list:

  • CMS-1500 claim form for all professional bills and their itemized statement
  • UB claim for all facility claims
  • Any ancillary service, like durable medical equipment or pharmacy charges – ask for an itemized statement
  • Please inform the provider that you are seeking all ICD and CPT codes associated with the services rendered

2.       Obtain relevant medical records representing services rendered.

3.       Have your medical audit specialist review the information and identify any anomalies or bills with insufficient information.

4.       If you hit road blocks such as “this information is only for insurance companies”, please remind the provider that billing information contains protected health information (PHI) and according to HIPAA, the patient is entitled to obtain their entire PHI.

5.       Finally with the right information you will be in a position to have an opinion generated on the bills associated with your case.

Send me a note if you get “stuck” or hit a “road block” in the process!

Thanks for reading!

Your healthcare resource – Rebecca Busch

Cutting Healthcare Costs through Patient Advocacy

Tuesday, July 12th, 2011

During a recent conversation with a colleague, she informed me how she has been responsible for taking care of her elderly mother, driving her to appointments, filling her prescriptions, etc. She mentioned that her mother’s previous doctor always ordered tests – looking at her bone density, mammograms, chest X-rays – the whole nine yards. Initially, this didn’t surprise me, her mother is 87 and has emphysema and osteoporosis – the doctor is just trying to keep her healthy. However, after my colleague enlightened me, I thought about the subject a little differently.

First of all, let’s look at the age. Her mother is 87. She has stated repeated that these tests hurt her (mammograms especially, and she has very sensitive skin that tears easily). Even if these tests were positive or showed some sort of abnormality, she would most likely elect not to have surgery, radiation, or other forms of treatment.  Her mother’s attitude, “I am 87, I want to live a pain free, non-complicated life. Going to the doctor every month isn’t fun for me, or my daughter who has to take work off in order to drive me.”

I mentioned previous doctor in the first paragraph because my colleague’s mother was so fed up with all these tests and appointments that she went to a new doctor. The new doctor was very candid. She said, “Yes, I can order these tests. Yes, I could see you once a month. However, you’re pretty healthy and these tests aren’t going to tell us anything that we don’t already know, or that we could fix.” Now, the doctor could have been reimbursed by Medicare and secondary insurance for these tests – the mother wouldn’t have had to “pay” out-of-pocket anything. But, in that sense, we all are paying for unnecessary tests and visits.

This is only part of the problem. Luckily my colleague and her mother were informed enough to understand that they can say, “No” to these unnecessary tests and procedures. Other individuals might be scared into participating. This is an instance were having a patient advocate on hand, informing the patient of his/her rights would be ideal. A second ear to listen to diagnoses and conditions, and a trained mind to realize that an elderly person who is sensitive might not want these tests because they hurt or the results won’t produce anything the person doesn’t already know.

The moral of this story is to speak up when communicating with your physician. If you find yourself wondering why your physician is ordering tests, consult with another physician. Patients can cut healthcare costs on the front end by being savvy consumers.

Thanks for reading!

Your healthcare resource – Rebecca Busch

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

Healthcare Reform and Businesses

Tuesday, June 14th, 2011

Current Healthcare Statistics:

•          Small businesses on average pay about 18% more than big businesses for the same health insurance policies

•          Small business health insurance premiums have risen 113% over nine years, a growth rate of nearly 9% annually

•          99% of large firms offer healthcare coverage, while 78% of firms with 10 to 24 workers offer coverage; that drops down to just 49% among firms with fewer than 10 workers

•          Of the 45 million uninsured Americans in 2007, 22.3 million (about half) were self-employed or worked for small businesses

Healthcare Reform Changes that Affect Your Business Right Now:

•          If you have 25 or fewer employees with annual wages of less than $50,000, you can get tax credits of up to 35% of the premiums paid under the new healthcare reform.

•          Catch: Employers need to cover at least 50% of the total premium cost for their employees

•          The credit will go up to 50% in 2014 and can be used for two consecutive years after that.

•          Businesses with 10 or fewer employees and annual wages of less than $25,000 will receive full access to the tax credit.

•          Small businesses that are tax-exempt are eligible for tax credits of up to 25% of the amount they contribute toward an employee’s health insurance premium.

•            4 million businesses are expected to be eligible for the credit this year

•          Holes: The IRS form that small business owners will fill out next year to claim the tax credit for 2010 is in draft form, and the IRS has not yet created instructions for how to use it

•          The Congressional Budget Office estimates that the credit could save small businesses $40 billion by 2019

What Can You Do to Trim Costs Right Now?

1.       Add a wellness or health management program

2.       Change plan design

3.       Perform a dependent eligibility audit

4.       Give incentives for employees to participate in wellness programs to improve the overall wellness of the group

Thanks for reading!

Your healthcare resource – Rebecca Busch

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

Audits Are Increasing “Thanks” to New Healthcare Laws

Wednesday, May 25th, 2011

Hospitals and physicians are experiencing a great number of audits due to new reform laws that hope to reduce healthcare fraud, waste, and abuse. The most recognizable type of audit – RAC (Recovery Audit Contractors) are paid on a contingency basis – meaning they do not get paid unless they discover the hospital or the specific provider is billing incorrectly or other audit rules that may apply.

What you may not know is that the government has MULTIPLE types of audit programs out there looking into hospitals, home health agencies, individual providers, and DME (durable medical equipment) companies in order to decrease reimbursement for coding issues, lack of documentation, and inaccurate documentation among many other things.

What types of audits should you be prepared for?

  • MAC (Medicare Administrative Contractor)

o   Compliance with ADMINISTRATIVE COSTS

  • PSC (Program Safeguard Contractor)

o   Looking for FRAUD, WASTE, & ABUSE

  • ZPIC (Zone Program Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • MEDIC (Medicare Drug Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • RVC (Recovery Audit Validation Contractors)

o   Looking for OVERPAYMENTS

  • QIC (Qualified Independent Contractors)

o   Compliance with ADMINISTRATIVE COSTS

  • MIC (Medicaid Integrity Contractors)

o   Compliance with PROGRAM INTEGRITY

Why is this happening?

According to the “Summary of the 2008 Financial Report of the United States Government,” in 2008, Medicare hospital insurance benefits began to exceed program tax revenues.

The bottom line is there is not enough money. Private insurance companies are following suit – the application of contractor audit methods are being applied RIGHT now.

Remember, it is not about preparing for any particular “audit” program – it is about developing internal controls, effective mitigation strategies, and an effective response to any third party.

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