In honor of Patient Advocacy Week that took place April 12th – 18th the focus of this commentary will relate to patient safety and self-advocacy.

In a recent RAND report “Is Better Patient Safety Associated with Less Malpractice Activity? Evidence from California” it was found that there is a correlation between the frequency of adverse events and malpractice claims. “On average, a county that shows a decrease of 10 adverse events in a given year would also see a decrease of 3.7 malpractice claims.” What this is telling us is that there is a link between patient safety and malpractice claims. While that might not necessarily be news to some, it does put some light on the “frivolous” lawsuits. If hospitals were to concentrate on patient safety and patient education the malpractice lawsuits will (according to this report) most likely decrease.

Another article by the Wall Street Journal titled “New Focus on Averting Errors: Hospital Culture” highlights the fact that errors made by healthcare professionals cause 44,000 to 98,000 deaths per year. To combat this number hospitals are taking a surprising approach: “Not only are they trying to improve safety and reduce malpractice claims, they’re also coming up with procedures for handling – and even consoling – staffers who make inadvertent mistakes.” Hospitals are taking a proactive approach to patient safety and staffer guidance instead of waiting for a bad event to occur and then reacting.

And now just a little information regarding Personal Health Records (PHRs) and their useful for patient safety. Having a PHR can certainly save you time and help with all the cumbersome paperwork, but having one can also save your life. Patient data is lost/mixed up etc. daily and having your own record of your health will help keep you safe. The state of California has the largest PHR adoption rate. Here is a look at the numbers:
1. 7% of adults had used a Personal Health Record (PHR)
2. California leads the nation in PHR use, at 15%
3. 58% of PHR users with two or more chronic conditions say they know more about their health care as a result, compared to 44% of those with only one or no chronic conditions
4. 48% of caregivers are interested in using a PHR for the person they care for
5. 75% worry about the privacy of PHR information
6. 40% of those who do not have a PHR express interest in using one

We have discussed types of healthcare fraud (i.e. Rent-a-Patient Schemes, Pill Mill Schemes, Drop Box Schemes & Third-Party Billing Schemes) in a previous post. However we didn’t highlight some new ways scammers and fraudsters are stealing your healthcare dollars, mainly through the online world.

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.

In a previous post, legal implications surrounding privacy standards with EHRs was discussed. The questions asked were: Are there enough safeguards surrounding the technology? Is it easier to steal patient information when records are in an electronic format? And the list goes on. The post did not address the advantages and shortcomings of the EHR technology. Adaptation is slow. Why is that?

A recent article from the Wall Street Journal “Can Technology Cure Health Care” stated that “digital medical records come with some big promises – they’ll improve patient care, eliminate errors, stem costs and make health care more efficient.” On the other hand a 2009 study indicated that “hospitals with more-advanced electronic systems fared NO better than other hospitals on measures of admin costs, on average, even if the systems might ‘modestly improve’ performance on care.”

What does that mean? Healthcare professionals are frustrated with the electronic systems. Could it be because healthcare – notoriously slow to change – isn’t ready for the switch? Unlikely – the article surmises that it might not have to do with how the digital records are implemented, but with how they are designed.

The article discusses how hospitals can customize digital systems to fit their own unique needs. Digital technology has a chance to revolutionize healthcare. We just need to come up with a system that is uniform enough so all systems can communicate, but unique enough to satisfy each health facilities’ needs and wants.

Medical Business Associates, Inc. President & CEO was featured in the Chicago Tribune Monday, April 5th 2010 in an article by Ann Meyer titled, “Consumer Education on Medical Spending a Key Component of Many Startups.”

The article explains that many small businesses will be faced with numerous choices due to the passage of healthcare reform.

Rebecca asserts that education is important when understanding healthcare reform and how it will affect your business. “The one thing you can control is educating the individual. We spend too much on healthcare not be educating the frontline.”

At the end of the article Rebecca also offers some tips about going about acquiring healthcare. Here is a highlight of what she had to say.
1. Watch out for fraudulent billing, counterfeit medication and medical identity theft. Interesting fact: Americans spend an average of $6,400 every second in healthcare fraud, waste and abuse compared with the estimated $3,400 per second the new legislation is expected to cost.
2. Ask about your bills – overbilling by healthcare providers contributes to the high cost of treatment. Make sure you understand what you are being charged AND for what you are being charged. Example a doctor might bill with a code that says you were at the office for 60 minutes when you only actually saw the doctor for 10.
3. Make sure you are buying insurance from a legitimate insurance provider. Rebecca states, “One of the fastest-growing areas is selling fake insurance.” Research a company before you buy insurance from them. Just remember the adage – if it looks to good to be true, it probably is.

Read full article here.

Two North Carolina doctors are in hot water after inducing labor and performing a C-section on a woman who wasn’t pregnant.

The doctors and several other interns tried to induce labor because the woman described only as “Patient A” came to the hospital claiming to be pregnant. Only after performing a Cesarean section did the doctors realize that the uterus was empty and the woman was in fact not pregnant.

The doctors later determined that the woman was suffering from pseudocyesis – also known as false pregnancy.

The two doctors in question were issued letters of concern but other doctors commenting on this story thought the punishment should be a little harsher. According to the article, “In this day and age, how can something like this happen? We have sonograms readily available to confirm whether or not someone is pregnant.”

An ultrasound was preformed by a resident (not the doctors in question), however, but it showed no heartbeat and “Patient A” insisted that she needed to be induced for fear of her baby.

The two doctors in question never actually examined the patient before they approved the C-section.

This is where we need to practice intelligent medicine and take the time to examine a patient. Doctors and nurses are extremely busy – especially in a hospital setting, but one simple examination would have shown that the woman was not actually pregnant and a major surgery (C-section) would not have been preformed.

Read full article here.

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.

“Blowing the whistle” on a former healthcare employer can lead to lottery like payouts. Recent whistleblowers are earning millions of dollars for their fraud reporting. Here are some highlights:

1. Pfizer whistleblower earns $51.5 million reward – with Pfizer having to pay $2.3 billion in penalties.
2. $2 million awarded to two New Yorkers for speaking out against their former nursing home employer – $24 million was paid back to the state.
3. A registered nurse received $4.9 million for her help in a Medicare fraud case that netted the U.S. Government $24 million.

However a recent Supreme Court ruling could change the nature of whistleblower lawsuits and the big individual payouts. The court has placed limits on existing whistleblower lawsuits claiming that local governments have misused federal money. The court voted 7 – 2 to hold that a technical, though important aspect of the federal whistleblower law applies to local governments. There is a section of the law that prohibits whistleblower lawsuits when public disclosure occurs through a court hearing, a news report or congressional/administrative audit. Read full article here.

It makes sense that once allegations are disclosed publicly, lawsuits are harder to file. If that wasn’t the case, people could hear about something on the news and head to the courthouse to file a claim. On the other hand, we need to make sure that people are still willing to file these claims against current or former employers who are guilty of wrongdoing. A previous post discussing two Texas nurses who are on trial for bringing claims against a doctor is a perfect example of what we are doing to NOT encourage people to stand up for what is right.

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.

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.

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 already failing healthcare system.

Read full article here.

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.