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Posts Tagged ‘Healthcare’

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.

Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting

Friday, December 10th, 2010

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.

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.

Healthcare fraud: How it affects the consumer

Monday, May 10th, 2010

Roughly 60 billion healthcare dollars are lost each year due to fraud, waste and abuse. How does this theft affect you the taxpayer and healthcare consumer?

The answer is surprisingly simply ­ it hits your wallet first. Insurance premiums are increasing at a staggering rate ­ 33% in the last five years. If this continues, most individuals will not be able to afford any type of insurance, costing taxpayers even more because they will be the ones footing the bill for the uninsured.

Insurance premium increases hit the employer even harder. Many times employers (especially small businesses) are forced to reduce their workforce to accommodate the rising costs or even cut healthcare benefits entirely.

Prescription drugs are an area that is greatly affected by fraud. Fraudsters are fans of selling counterfeit medication. Consumers ingesting this medication (many times laced with poison ­boric acid for example) can end up in the emergency room with complications costing thousands.

The recent passage of Healthcare Reform is also proving to be good news for fraudsters. Many consumers have little to no knowledge of the bill and scammers have found multiple ways to cheat the innocent out of their money.

Fraudsters prey on the fear and confusion brought about by the bill. Going door-to-door selling fake insurance, scammers advertise an “ObamaCare” plan and insisting consumers better act fast due to a “limited enrollment” period. These scams bilk consumers out of thousands of dollars and leave them without any real insurance, so if a medical emergency where to occur, they would be left footing the bill.

So, what can the consumer do to help combat healthcare fraud? First, understand exactly what you’re being charged for and always ask for clarification on any charges for services that you do not recognize. Second, know where your medical identification is and alert proper authorities when your insurance card has been stolen ­ medical identity theft crimes can leave you sorting out medical bills for the rest of your life. Finally, be a conscientious healthcare consumer. Be aware of current fraud schemes and check out the Food & Drug Administration website to ensure your medication is not on the counterfeit list.