The Kaiser Family Foundation and the Health Research and Educational Trust (HRET) perform an annual survey regarding the nature of employer-sponsored health benefits at nonfederal private and public companies nationwide. This is the twelfth such survey. The results are grim, for employees at least.

It’s no longer news that healthcare costs are on the rise. Most have begun to brace themselves for cost increases as a result of healthcare reform. In our recent blog post on the NNNN survey we reviewed the plans of large employers to pass the cost increase onto employees in 2011. For the most part, we are prepared to see our healthcare costs rise after the reform takes effect. But we don’t have to wait to feel these increases. Across the board, the average employee has already seen these increases. The survey certainly shows increases- especially in premiums for family and individual plans. The most notable increase may be that seen in the employee contribution.

Historically, employers and employees have shared the burden of rising premium costs. In 2010, however, employers did not increase their dollar-amount contribution. As a result, employee contribution rose 14% from 2009. Employer contribution did not rise.

The survey reports that 27% of employees have deductibles of $1,000 or more for single coverage. This is up from 22% in 2009. The average deductible is considerably less for workers with PPOs or HMOs. Prescription drugs, physicians visits, and preventative care are usually covered (with, of course, a co-pay or coinsurance) before a deductible is met. The out-of pocket maximum varies considerably for workers and plans.

Where are you better off, a large firm or a small firm? For the most part, it’s hard to tell. But, if you’re hoping to pay less of your premium, start sending your resume to small companies. 35% of employees at small firms pay nothing towards single coverage premium and 13% pay nothing towards family coverage. Only 6% at large firms pay nothing for single coverage and 1% towards family coverage.

Employers were not shy about reporting the changes nor the reasons for them.  Increased cost sharing, reduction in the scope of coverage, and increased employee contribution were all responses to the poor economy.

Keep in mind that this survey was conducted from January to May 2010. After our previous post on Large Employers passing rising health costs onto employees, we can only imagine what the survey will show in 2011.

With the holidays right around the corner, many of us will be rushing around, finishing up holiday shopping, attending parties, eating too much… the list goes on.

However, people still get hurt and sick around the holidays and are in the hospital. Hospital staff is lighter around the holidays, giving providers some much needed family time. On the other hand, less providers and tired staff can lead to medical errors.

A recent article by Dr. Bialek of www.covermd.com looks at the top ten most common medical errors in the United States.

1. Technical medical error
Ex: Provider cutting the wrong artery in a heart surgery, leading to complications or death.

2. Failure to use indicated tests
Ex: Patient having chest pains, but doctor failing to perform an EKG and patient has a heart attack.

3. Avoidable delay in treatment
Ex: Patient complains of stomach pains, isn’t seen quickly by ER attendees because of more urgent manners, patient’s appendix erupts causing severe internal bleeding.

4. Failure to take precautions
Ex: Patient is weak and has a history of falling. Nurse takes patient from the bed to the bathroom, unaware of patient’s weakness. Patient falls and fractures hip.

5. Failure to act on test results
Ex: Patient feels dizzy and sick. Doctor orders blood test, believes it’s an infection and sends the patient off with antibiotics. Test results come back, but doctor fails to look at them thinking she just has an infection. Patient ends up in a diabetic comma.

6. Inadequate monitoring after a procedure
Patient has a routine surgery. After surgery, patient is on narcotics. Nurses fail to monitor the patient, although patient’s parents are in the room. They do not realize that the patient has stopped breathing.
Another important list is errors with serious consequences. These occur mostly in intensive care units, operating rooms, and emergency departments.

7. Inadequate patient preparation before a procedure
Patient goes in for surgery. The provider fails to check with the patient to see what medications the patient is taking before surgery is performed. The patient is currently taking a blood thinner. During surgery and bleed occurs and the patient dies.

8. Inadequate follow-up after treatment
Patient has surgery. After surgery the doctor tells the patient to call for any changes in temperature, feeling, etc. Patient feels drowsy and nauseous from anesthesia and blames it on that. When the patient calls the doctor, the doctor tells the patient to wait 24 hours. Patient comes down with a deadly infection.

9. Avoidable delay in diagnosis
Patient comes in after blacking out after being assaulted. Provider waits 12 hours for a CT scan. Patient’s brain is bleeding and never wakes up.

10. Improper medication dose and/or method of use
Ex: A drug mix up causes a patient to take 10 times the normal dose. Patient dies a result.

On Wednesday, Rebecca participated in a Webinar for an Illinois Workers’ Compensation Association. She presented on the topic “Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting.” In front of an audience of case managers, attorneys, human resource personnel and other healthcare professionals, Rebecca had a lively discussion on many aspects of healthcare fraud in a Workers’ Compensation setting.

Some highlights include:
Overall numbers –
The Insurance Information Institute estimates that all property/casualty insurance fraud cost insurers $30 billion annually.

Workers’ Compensation fraud accounts for approximately 25% or $7.2 billion a year, according to the National Insurance Crime Bureau (NICB).

The NICB characterizes Workers’ Compensation fraud as the “fastest growing segment of insurance fraud” in the nation.

Most studies indicate that the three parties primarily driving the cost of workers’ comp fraud are employers, medical providers, and employees.

Tips on spotting fraud:
Worker Claim Fraud
• Number of days worked and amount of salary inconsistent with occupation
• Injured worker disputes average weekly wage due to additional income (i.e., per diem and/or 1099 income)
• Cross-outs, white-outs and erasures on documents
• Injured worker files for benefits in a state other than principle location of the alleged industrial injury or occupational disease
• Injured worker-listed occupation is inconsistent with employer’s stated business
Employer Fraud
• Business displays or presents a Certificate of Coverage that contains inaccurate data, such as an implausible period of coverage
• Cross-outs, white-outs and/or erasures on documents, such as the Application for Ohio Workers’ Compensation Coverage (U-3) or Payroll Report (DP-21)
• Business name is not consistent with type of work being performed
• Number of employees, classifications and payroll are inconsistent
Provider Fraud
• Injured worker does not recall having received the billed service
• Provider’s medical reports read almost identically even though they are for different patients with different conditions
• Much higher healthcare costs than expected for the allowed injury type
• Frequency of treatments or duration of treatment period is greater than expected for allowed injury type, especially for older (non-catastrophic) claims

When investigating workers’ compensation fraud, always request detailed medical records and records of the injury. If all the facts don’t add up – you might be looking at fraudulent activity.

A recent Wall Street Journal article explained that employers are taking new initiatives to decrease healthcare costs. One simple solution employers are turning to – dependent eligibility audits. Dependents costs employers around $2,100 per year and an average of 2 – 10% of all dependents are ineligible.

Typically employers do not require employees to submit documents to confirm the eligibility of dependents – many currently use the honor system, entrusting that employees aren’t out the cheat their employers. However, times are tough and employers are viewing these dependent eligibility audits as an easy way to cut cost without laying off employers or decreasing health benefits.

So how do the audits typically work? Medical Business Associates, Inc. conducts electronic audits using a secure sever and email communication. Typically, there is an amnesty period for employees to drop dependents without penalty. Then employers receive information about required documents for each dependent. Employees then upload, mail or fax the required information to keep their dependents on the plan.

According to a CNN article, removing ineligible dependents could save companies between 4% to 6% of their annual healthcare costs. With Medical Business Associates, Inc. electronic solution, all required documents are stored, so if a company decides to conduct a follow up audit, employees will not be required to submit duplicate birth or marriage certificates if dependents status hasn’t changed.

For more information on MBA’s audit solution visit here.

A recent report highlighted that more than 13 % of Medicare patients in the U.S. experience an adverse event each month in American hospitals – resulting in 15,000 deaths.

AOL Health’s recent article states, “The news is startling, particularly since the report points out that 44 % of adverse incidents occurring in hospitals are avoidable. And all-together, these adverse events are costing Medicare more than $300 million a month.”

Now what are some types of medical errors that have occurred?
1. A doctor operated on and amputated the wrong leg of a veteran.

2. An elderly woman received the wrong blood type during a blood transfusion.

3. A CT scan being performed on a pregnant woman who had a similar name to a patient who was having abdominal pain resulting in harm to the unborn baby.

Link to other, unforgivable medical errors.

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.

This past month I was double billed for tickets to a sporting event and charged for services at a health club that I did not receive. My credit card company did not “catch” this activity (nor did they have the information to know that the charges were incorrect – and perhaps fraudulent). I was able to reverse the charges because I understand how to read my credit card statement and can monitor it for inappropriate charges. Imagine if we empowered employees to look at healthcare the same way.

By recognizing how and when employees can add value, organizations can learn useful ways to influence their growth. With the challenge of increasing healthcare costs, employees can also help their organizations reduce their healthcare costs – and even prevent their organizations from being victims of healthcare fraud.

People are good consumers – of automobiles, home appliances, engagement rings and just about any other purchase that deeply affects their own “bottom lines”. Now that payors are shifting more expense to patients through co-payments, out-of-pocket expenses, deductibles, etc. and patients have greater access to healthcare information then ever before, it is the right time to get employees engaged in their healthcare expenditures. Clearly when an employee makes a better financial healthcare decision, their employer also benefits.

Because of the complexity of our healthcare system, it is important to teach employees how to be effective healthcare consumers and arm them with accurate information to make optimal decisions about their care. Patient Advocates help patients navigate our healthcare system – and can train employees to gather, assemble and use information to mange, control and reduce their medical expenses. Critical information that employees need to understand to make informed healthcare decisions include, but are not limited to:

1. Medical records

2. Beneficiary rules

3. Healthcare bills

4. Explanation of Benefits (EOBs)

5. Clinical quality outcome measures

The key is for organizations to explain to employees the incentives of being a conscientious healthcare consumer, including but not limited to:

1. Preventing costly clinically adverse outcomes

2. Preventing inappropriate payments for healthcare services and products

3. Safeguarding personal healthcare information from Medical Identity Theft

People know how to be conscientious consumers – we just need to teach them how to be conscientious healthcare consumers.

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.

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.

Below are her 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.

With the new rules and incentives reported in the Patient Protection and Affordable Care Act, we are seeing more whistleblowers come forth alleging healthcare fraud. Currently, 90% of health care fraud cases are whistleblower cases — often in which the behavior of the “ethically challenged” directly poses risks to public health.

Regardless of whether whistleblowers are concerned citizens, disgruntled employees or senior executives with a “lottery mentality”, hospitals and other healthcare companies must have strong compliance programs in place to stop fraudulent activity — such as improperly billing Medicare and Medicaid and kickbacks to doctors. A list of healthcare companies that have signed corporate integrity agreements with the OIG can be found here.

With the new incentives, hospitals and other healthcare companies are even more susceptible to whistleblowers. Now is the time to review your current compliance program and develop the necessary internal controls to protect your organization from committing fraud. Below are 4 simple but important considerations to keep in mind when evaluating compliance programs:

1. Periodic comprehensive fraud risk assessments are conducted.
2. Standards of conduct for employees are written and distributed.
3. Educational and training programs are offered to all employees.
4. Audits are conducted to monitor compliance and identify problem areas.

The effectiveness of whistleblowers is also an integral part of the effort to combat healthcare fraud. The first thing people need to do when encountering fraudulent activity in their workplace is to make sure that they understand the reporting framework and seek appropriate legal counsel. As an expert witness, I have seen first-hand the enormous complexity of whistleblower suits.