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.

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.

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.

Names have been changed to protect the innocent.

A scary night in the ER

“I have been watching my friend for the last 24 hours. First in the ER being monitored by a machine for his heart, oxygen and blood pressure – the alarm is turned off so it doesn’t make any noise – followed by a 6 hour wait for EMERGENCY surgery – hoping that he gets in the cue prior to the onset of internal rupture. I watched patient transport almost pull him out of the room without disconnecting the tubes from the wall – a frustrating reminder that the focus on reform is not about health.

After surgery I was watching him recover and yet again the $200 monitor has the alarm turned off. I thought to myself, ‘I wonder what would happen is there was no one in the room and he couldn’t call out for help?’

My friend received a 2mg narcotic through his IV around 6:00 pm. At 8:00 pm the nurse came back to evaluate for another .5mg of the narcotic. I watched his nurse place the injection on the table, take and enter vital signs into the bedside PC and while I was looking at my notes, the nurse left the room. I asked my friend, “Did the nurse give you anything?” He didn’t know. I looked for injection marks on his right arm – nothing. I walked out and asked the nurse, “Did you give him the injection?” The nurse’s response, “You were in the room the whole time, did you not see me give it to him?”

I took a step back – I am tired and need to turn off my fraud, waste and abuse examiner’s hat. However, I wonder on these points…

1. I believe the nurse stole the narcotic and did not give it to the patient. The next day the floor nurse let me look at the medical record. The patient received the narcotic at 8:00 pm IVP – which means the nurse would have had to ask me to move since I was sitting next to the arm with the IV.

2. The on call surgeon had to wait until the on call surgical staff finished operating on the patient’s rupture appendicitis. He was ready for surgery at 10:00 pm but could not get in until 1:00 am. So what would have happened if the bowel obstruction ruptured any time before 1:00 am? Would he have died in the ER? Been transferred to another hospital?

3. What would have happened on the snowy icy night if an auto accident had been admitted? Would he have been bumped? Did the hospital put their ER in bypass mode?

4. Now what about the ER nurse, did he take the narcotic himself? Was he feeling a little ‘happy’?

In our current economic forecast with fraud running rampant (the Madoff scandal, the collapse of the financial market etc.) the False Claims Act is still relevant. Even with the abundance of accounting fraud, the major focus of the False Claims Act is still healthcare fraud. According to an article in the American Medical News, “Healthcare cases made up the lion’s share of false claims settlements and judgments in the fiscal year, brining in $1.6 billion, or two-thirds of the total $2.4 billion recouped.

Read full article here.

Healthcare fraud is a huge industry for the ethically challenged in our country. Keep reporting – it is a great deterrent.

See article for more information.

With the increasingly high costs of prescription medications, many people are turning to the Internet to fill their prescriptions. Internet pharmacies are a hot bed for counterfeit drugs. However, don’t assume you’re safe if you purchase from a brick and mortar pharmacy – counterfeit drugs can make their way into the supply chain anywhere.

Counterfeit drugs are currently a $28 million industry. Don’t let yourself be a victim. Below are some tips that will help.

1. 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. If you only receive the pill in a generic bottle compare a picture of the tablet at www.fda.gov by simply searching for the medication.

3. If you are taking a medication and it just doesn’t feel the same or is not working like it normally does, see your doctor and show the medication to your pharmacist.

4. If the medication is deemed counterfeit, save a sample until you see your doctor to make sure there will be no long term complications or side effects.

The bipartisan bill would end the common practice of mailing reimbursement checks to post office boxes. However, we first should all be asking a very important question. Who thought it was responsible to send reimbursement checks to post office boxes in the first place? What reputable healthcare provider doesn’t have a permanent address where to send checks?

The Act will mandate that all government sponsored health programs pay healthcare providers and suppliers by using direct deposit. This certainly seems to be a step in the right direction and into the 21st century. Direct deposits will eliminate an easy way for criminals to get their hands on reimbursement checks, save the government money on stamps, envelopes, paper check etc., and don’t forget about the environment.

Congress, please say, “Yes,” to healthcare reform.

WellPoint – an independent licensee of Blue Cross and Blue Shield – also announced that they recovered $75 million due to waste, fraud and abuse in their system. According to their estimates, for every $1 spent on investigating fraud the company saves or recovers $11.

Read full article.

If insurance companies can find ways to combat waste, fraud and abuse in their systems, Medicare and Medicaid need to find more productive methods. An estimated $68 billion every year – or 3% – of all healthcare expenditures is stolen. The government could insurance millions with that “extra” money.

2 to 4 million people have purchased what they thought to be medical discount cards, only to later learn they had been misled and ripped off. Consumers buying these cards are likely to not have insurance from their jobs and can’t afford it on their own. These cards seem to be a winning solution.

Make sure you’re not a victim.

Read full article here.