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Posts Tagged ‘Healthcare Fraud’

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

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

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

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.

Employees Are the First Line of Defense

Thursday, November 4th, 2010

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.

Knowledge Lowers Healthcare Costs

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.

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

Doctors try to have non-pregnant woman give birth

Monday, April 5th, 2010

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.

Whistle blower to stand trial for reporting doctor

Saturday, February 27th, 2010

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.

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.