Tuesday, 29 July 2014

Special Fraud Alert: Laboratory Payments to Referring Physicians

I. The Anti-Kickback Statute
One purpose of the anti-kickback statute is to protect patients from inappropriate medical referrals or recommendations by health care professionals who may be unduly influenced by financial incentives. Section 1128B(b) of the Social Security Act (the Act) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce, or in return for, referrals of items or services reimbursable by a Federal health care program. When remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute a scribes criminal liability to parties on both sides of an impermissible “kickback” transaction. Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to 5 years, or both. Conviction will also lead to exclusion from Federal health care programs, including Medicare and Medicaid. OIG may also initiate administrative proceedings to exclude persons from the Federal health care programs or to impose civil money penalties for fraud, kickbacks, and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act.

II. Remuneration From Laboratories to Referring Physicians
Arrangements between referring physicians and laboratories historically have been subject to abuse and were the topic of one of the OIG’s earliest Special Fraud Alerts.
1 In that Special Fraud Alert, we stated that, “[w]henever a laboratory offers or gives to a source of referrals anything of value not paid for at fair market value, the inference may be made that the thing of value is offered to induce the referral of business.” More generally, we have, on various occasions, repeated our position that arrangements providing free or below-market goods or services to actual or potential referral sources are suspect and may violate the anti-kickback statute, depending on the circumstances.
2 Likewise, when a laboratory pays a physician more than fair market value for the physician’s services or for services the laboratory does not actually need or for which the physician is otherwise compensated, the anti-kickback statute is implicated. Such payments are suspect under the anti-kickback statute because of the implication that one purpose of the payments is to induce the physician’s Federal health care program referrals. OIG also historically has been concerned with arrangements in which the amounts paid to a referral source take into account the volume or value of business generated by the referral source. Arrangements in which laboratories provide free or below-market goods or services to physicians or make payments to physicians that are not commercially reasonable in the absence of Federal health care program referrals potentially raise four major concerns typically associated with kickbacks—corruption of medical judgment, overutilization, increased costs to the Federal health care programs and beneficiaries, and unfair competition. This is because such transfers of value may induce physicians to order tests from a laboratory that provides them with remuneration, rather than the laboratory that provides the best, most clinically appropriate service. Such transfers of value also may induce physicians to order more laboratory tests than are medically necessary, particularly when the transfers of value are tied to, or take into account, the volume or value of business generated by the physician. We are particularly concerned about these types of arrangements because the choice of laboratory, as well as the decision to order
laboratory tests, typically is made or strongly influenced by the physician, with little or no input from patients. Although physicians may order any tests they believe are appropriate to diagnose and treat their patients, Medicare will pay for laboratory tests only if they meet Medicare coverage criteria and are reasonable and necessary.3
Moreover, claims that include items or services resulting from a violation of the anti-kickback statute are not payable by Medicare and may constitute false claims under the False Claims Act, even if the items or services are medically necessary.4 OIG recognizes that the lawfulness of any particular arrangement under the anti-kickback statute depends on the intent of the parties. Such intent may be evidenced by the arrangement’s characteristics, including its legal structure, its operational safeguards, and the actual conduct of the parties to the arrangement. Nonetheless, we believe the following types of arrangements between laboratories and physicians are suspect under the anti-kickback statute.

A. Blood-Specimen Collection, Processing, and Packaging Arrangements
OIG has become aware of arrangements under which clinical laboratories are providing
remuneration to physicians to collect, process, and package patients’ specimens. This Special Fraud Alert addresses arrangements under which laboratories pay physicians, either directly orindirectly (such as through an arrangement with a marketing or other agent) to collect, process, and package patients’ blood specimens (Specimen Processing Arrangements).5 Specimen Processing Arrangements typically involve payments from laboratories to physicians for certain specified duties, which may include collecting the blood specimens, centrifuging the specimens, maintaining the specimens at a particular temperature, and packaging the specimens so that they are not damaged in transport. Payments under Specimen Processing Arrangements typically are made on a per-specimen or per-patient-encounter basis and often are associated with expensive or specialized tests.Medicare allows the person who collects a specimen to bill Medicare for a nominal specimen collection fee in certain circumstances, including times when the person draws a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacuum tube to draw the specimen).6 Medicare allows such billing only when: (1) it is the accepted and prevailing practice among physicians in the locality to make separate charges for drawing or collecting a specimen and (2) it is the customary practice of the physician performing such services to bill separate charges for drawing or collecting the specimen.7 Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn.8Physicians who satisfy the specimen collection fee criteria and choose to bill Medicare for the specimen collection must use Current Procedural Terminology (CPT) Code 36415, “Routine venipuncture – Collection of venous blood by venipuncture.
OIG has become aware of arrangements under which clinical laboratories are providing
remuneration to physicians to collect, process, and package patients’ specimens. This Special Fraud Alert addresses arrangements under which laboratories pay physicians, either directly or indirectly (such as through an arrangement with a marketing or other agent) to collect, process, and package patients’ blood specimens (Specimen Processing Arrangements).5 Specimen Processing Arrangements typically involve payments from laboratories to physicians for certain
specified duties, which may include collecting the blood specimens, centrifuging the specimens, maintaining the specimens at a particular temperature, and packaging the specimens so that they are not damaged in transport. Payments under Specimen Processing Arrangements typically are made on a per-specimen or per-patient-encounter basis and often are associated with expensive or specialized tests.Medicare allows the person who collects a specimen to bill Medicare for a nominal specimen
collection fee in certain circumstances, including times when the person draws a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacuum tube to draw the specimen).6 Medicare allows such billing only when: (1) it is the accepted and prevailing practice among physicians in the locality to make separate charges for drawing or collecting a specimen and (2) it is the customary practice of the physician performing such services to bill separate charges for drawing or collecting the specimen.7 Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn.8 Physicians who satisfy the specimen collection fee criteria and choose to bill Medicare for the specimen collection must use Current Procedural Terminology (CPT) Code 36415, “Routine venipuncture – Collection of venous blood by venipuncture.

·       * Payment exceeds fair market value for services actually rendered by the party receiving the payment.
·         Payment is for services for which payment is also made by a third party, such as
·      * Payment is made directly to the ordering physician rather than to the ordering physician’s group practice, which may bear the cost of collecting and processing the specimen.
·       * Payment is made on a per-specimen basis for more than one specimen collected during a single patient encounter or on a per-test, per-patient, or other basis that takes into account the volume or value of referrals.
·         * Payment is offered on the condition that the physician order either a specified volume or type of tests or test panel, especially if the panel includes duplicative tests (e.g., two or more tests performed using different methodologies that are intended to provide the same clinical information), or tests that otherwise are not reasonable and necessary or reimbursable
·         * Payment is made to the physician or the physician’s group practice, despite the fact that the specimen processing is actually being performed by a phlebotomist placed in the physician’s office by the laboratory or a third party.

OIG’s concerns regarding Specimen Processing Arrangements are not abated when those arrangements apply only to specimens collected from non-Federal health care program patients. Arrangements that “carve out” Federal health care program beneficiaries or business from otherwise questionable arrangements implicate the anti-kickback statute and may violate it by disguising remuneration for Federal health care program business through the payment of amounts purportedly related to non-Federal health care program business. Because physicians typically wish to minimize the number of laboratories to which they refer for reasons of
convenience and administrative efficiency, Specimen Processing Arrangements that carve out Federal health care program business may nevertheless be intended to influence physicians’ referrals of Federal health care program business to the offering laboratories. Finally, because the anti-kickback statute ascribes criminal liability to parties on both sides of an impermissible “kickback” arrangement, physicians who enter into Specimen 


Tuesday, 22 July 2014

That’s where the money is

MEDICAL science is hazy about many things, but doctors agree that if a patient is losing pints of blood all over the carpet, it is a good idea to stanch his wounds. The same is true of a health-care system. If crooks are bleeding it of vast quantities of cash, it is time to tighten the safeguards.

In America the scale of medical embezzlement is extraordinary. According to Donald Berwick, the ex-boss of Medicare and Medicaid (the public health schemes for the old and poor), America lost between $82 billion and $272 billion in 2011 to medical fraud and abuse (see article). The higher figure is 10% of medical spending and a whopping 1.7% of GDP—as if robbers had made off with the entire output of Tennessee or nearly twice the budget of Britain’s National Health Service (NHS).
Crooks love American health care for two reasons. First, as Willie Sutton said of banks, it’s where the money is—no other country spends nearly as much on pills and procedures. Second, unlike a bank, it is barely guarded.

Some scams are simple. Patients claim benefits to which they are not entitled; suppliers charge Medicaid for non-existent services. One doctor was recently accused of fraudulently billing for 1,000 powered wheelchairs, for example. Fancier schemes involve syndicates of health workers and patients. Scammers scour nursing homes for old people willing, for a few hundred dollars, to let pharmacists supply their pills but bill Medicare for much costlier ones. Criminal gangs are switching from cocaine to prescription drugs—the rewards are as juicy, but with less risk of being shot or arrested. One clinic in New York allegedly wrote bogus prescriptions for more than 5m painkillers, which were then sold on the street for $30-90 each. Identity thieves have realised that medical records are more valuable than credit-card numbers. Steal a credit card and the victim quickly notices; photocopy a Medicare card and you can bill Uncle Sam for ages, undetected.

It is hard to make such a vast system secure: Medicare’s contractors process 4.5m claims a day. But pointless complexity makes it even harder. Does Medicare really need 140,000 billing codes, as it will have next year, including ten for injuries that take place in mobile homes and nine for attacks by turtles? A toxic mix of incompetence and political gridlock has made matters worse. Medicare does not check new suppliers for links to firms that have previously been caught embezzling (though a new bill aims to fix this). Fraud experts have long begged the government to remove Social Security numbers from Medicare cards to deter identity thieves—to no avail.

Start by closing the safe door
One piece of the solution is obvious: crack down on the criminals. Obamacare, for all its flaws, includes some useful measures. Suppliers are better screened. And when Medicaid blackballs a dodgy provider, it now shares that information with Medicare—which previously it did not. For every dollar spent on probing health-care fraud, taxpayers recover eight. So the sleuths’ budgets should be boosted, not squeezed, as now.

But the broader point is that American health care needs to be simplified. Whatever its defects, Britain’s single-payer National Health Service is much simpler, much cheaper and relatively difficult to defraud. Doctors are paid to keep people well, not for every extra thing they do, so they don’t make more money by recommending unnecessary tests and operations—let alone billing for non-existent ones.

Too socialist for America? Then simplify what is left, scale back the health tax-perks for the rich and give people health accounts so they watch the dollars that are spent on their treatment. After all, Dr Berwick’s study found that administrative complexity and unnecessary treatment waste even more health dollars than fraud does. Perhaps that is the real crime.


Monday, 21 July 2014

False medical claims

The scams
Phantom treatments. Dishonest medical providers will bill health insurers for expensive treatments, tests or equipment you never received - and for illnesses or injuries you don't even have.

Double billing. Unethical providers may double- or triple-bill health insurers for the same treatments, hoping the insurer won't discover the overruns in the big stack of bills.

Shoddy care. You might receive shoddy or substandard treatment for real and urgent medical problems. One eye doctor shined pen lights into patients' eyes and said he'd performed cataract surgery. Surgeons have used defective pacemakers and catheters during heart surgeries, which have killed patients or required more surgeries to correct the problems.

Unneeded care. You might receive dangerous and even life-threatening treatment you don't need. One surgeon performed heart surgery on patients who didn't need it.

Bogus insurers. Insurance agents or brokers sell you low-cost health coverage from fake insurance companies. Then they take your premiums and disappear. You're left without vital health coverage, and don't even know it until you make a claim.

Identity theft. Cheaters steal your medical ID number, then use it to bill health programs tens of thousands of dollars for phantom treatment. Crooks steal your health info from dumpsters behind medical clinics, break into doctor offices and steal files, and hack into computer databases containing your records.

Rolling labs. Mobile diagnostic labs give needless or fake tests or physical exams to consumers, then bill health insurers for expensive procedures.

Runners. A person hired by a medical provider to drum up business trolls through neighborhoods, often low-income areas, enticing people to come to a clinic for tests. These runners will even round up children for unneeded tests and procedures.

The price you pay
Coverage drained. Your coverage limits might be drained by worthless and unnecessary treatments.

Financial disaster. Inflated or phantom medical bills can increase your co-payment, beyond your ability to pay. This could force you into collections and damage your credit rating. And if you bought health insurance that ends up completely fake, you could face financial disaster if you must pay large medical bills with your life savings because your policy's worthless.

False medical record. Your medical record contains false information about illnesses, diseases, injuries or other problems you never had. Your information is available to insurers, so you could be denied health coverage or pay higher premiums because of a trumped-up medical record.

Premiums rise. Your health premiums rise because insurers pass the cost of fraud onto policyholders. High health premiums discourage employers from offering this needed employee benefit.

Personal distress. You receive bogus or needless treatments that are painful, distressing, can threaten your health — and even kill you.

Taxpayer ripoff. Billions of your tax dollars pay for fraudulent claims against Medicare, Medicaid and other taxpayer-funded health programs every year. These are your tax dollars being stolen.

Fight Back
• Keep detailed records of treatments you receive. Include all dates, locations, who provided the treatments, what services you received, and what medicine, supplies or equipment were provided.

• Carefully review the billing and summary statements you receive after treatment. Are the treatment dates, doctor name(s), facility locations and medical services the same as you remember? Know what medical equipment and supplies your provider ordered, as well.

• Never sign blank insurance claim forms.

• Ask your medical providers what price they charge, and what you'll pay out-of-pocket.

• Avoid door-to-door or telephone salespeople who offer you free medical services or equipment.

• Never give strangers your policy number, insurance ID number, Medicare claim number or other info, especially if they offer you cash or free gifts, treatments or equipment.

• Know what your medical benefits are — what's covered and what isn't.

• Back off if someone says they can bill your health program to pay for an uncovered treatment or equipment. You're being pulled into an illegal scheme. You could lose your health coverage, be arrested, fined, thrown into jail, and live with a conviction record that disrupts your life for years to come.

• Never pay your health premiums in cash, and be wary if the health insurer asks you to pay a full year's premium upfront.

• Be careful if medical providers say they're connected with the federal government, Medicare, Medicaid or other health programs.

• Back off if the insurer offers you health coverage for "just pennies a day," or sells coverage at a price far lower than others.

• Check with your state insurance department to make sure the health insurance company is licensed to do business in your state.

• See if the health insurer has a history of consumer complaints, bankruptcy, fraud convictions or other problems. Your state insurance department and consumer protection agency, and Better Business Bureau are good places to start.


Sunday, 20 July 2014

Medicare card and identity theft; help to get cell phones

Dear Savvy Senior,
I just turned 65 and received my Medicare card. I see that the ID number on my card is the same as my Social Security number, and on the back of the card it tells me I need to carry it with me at all times. What can I do to protect myself from identify theft if my purse and Medicare card get stolen?

Answer: Many people new to Medicare are surprised to learn that the ID number on their Medicare card is identical to their Social Security number (SSN). After all, we’re constantly warned not to carry our SSN around with us, because if it gets lost or stolen, the result could be identity theft.
But the Medicare ID is more than an identifier. It’s proof of insurance. Beneficiaries need to show their Medicare card at the doctor’s office and the hospital in order to have Medicare pay for treatment.
Over the years, many consumer advocates, have called for a new form of Medicare identification. The Centers for Medicare & Medicaid Services, which administers Medicare, also acknowledges the problem, but so far nothing has been done.
One of the main reasons is because it would cost an estimated $255 to $317 million to fix it. And that’s just the direct cost to the federal government. It doesn’t include the expense for physicians and other health care providers to adjust their systems, or the cost to the states.
Other government health systems like the Department of Veterans Affairs and Department of Defense have already begun using ID numbers that are different from SSNs, but no one knows when Medicare will follow suit.
In the meantime, here are some tips offered by various consumer advocate groups that can help keep your Medicare card safe and out of the hands of fraudsters.
• For starters, AARP suggests that you simply don’t carry your Medicare card at all, because it’s not necessary. Most health care providers already have their patients in their electronic systems and know how to bill you.
• But if you really don’t feel comfortable not having it with you, then the Privacy Rights Clearing House, a national consumer resource on identity theft recommends that you make a photocopy of your card and cut it down to wallet size. Then use scissors to cut out the last four digits of your SSN, or take a black marker and cross them out, and carry that instead.
You will, however, need your actual Medicare card with you the first time you visit a new health care provider, who will likely want to make a photocopy of it for their files.
If you’re worried that you’ll need your card in an emergency situation in order to get care, you should know that emergency personnel cannot refuse you care until you show an insurance card. Although you’ll need to come up with billing information before leaving a hospital, that doesn’t mean you won’t receive care

Lost or stolen
If your Medicare card does happen to get lost or stolen, you can replace it by calling Social Security at 800-772-1213. You can also apply for a new card online at ssa.gov/medicarecard or go to your local Social Security office.
If your Medicare card has been lost or stolen, you will need to watch out for Medicare fraud. You can do this by checking your quarterly Medicare summary notices for services or supplies you did not receive. If you spot anything suspicious or wrong, call the Inspector General’s fraud hotline at 800-447-8477.
If you need help identifying Medicare fraud, contact your state Senior Medicare Patrol program. See smpresource. org or call 877-808-2468 for contact information.

Dear Savvy Senior,
What are the cheapest cell phone options available today to seniors living on a shoestring budget? I only need it for occasional calls.

Answer: For financially challenged seniors who only want a cell phone for emergency purposes or occasional calls, there are a number of inexpensive no contract plans you can get. Or, depending on your income level, there are also free cell phones and monthly airtime minutes you may qualify for. Here’s where to find some of the cheapest deals.  
One way infrequent cell phone users can save money is with a prepaid cell phone – also known as pay-as-you-go phones. With a prepaid phone, there’s no contract, no fixed monthly bills, no credit checks and no hidden costs that come with traditional cell phone plans. With this type of service, you buy a special prepaid phone then pre-purchase a certain amount of minutes (for talk or text) that must be used within a specified period of time.
While most major carriers like AT&T and Verizon offer inexpensive prepaid plans, as do independents like Net10, Cricket and Virgin Mobile, some of the best deals are offered by TracFone (tracfone. com, 800-867-7183) and T-Mobile (t-mobile.com, 800-866-2453).
TracFone has phones that start as low as $10 and call plans that cost under $7 per month. And T-Mobile has a super-cheap 30-minute plan for $10, and minutes don’t expire for 90 days. That averages out to $3.33 per month. If you need more talk time, they also offer an annual plan where $100 gets you 1,000 minutes that are good for a full year. T-Mobile does, however, charge a one-time activation of $35.
Or, it you would rather have a no-contract senior-friendly phone with big buttons and simplified features, the Doro PhoneEasy 618 sold through Consumer Cellular (consumercellular.com, 888-345-5509) is probably your cheapest option. It costs $60 for the phone, with calling plans that start at $10 per month.
If your income is low enough, you also need to check into the Lifeline Assistance Program. This is a government-sponsored program that subsidizes wireless (and landline) companies who in turn provide free cellphones and around 250 minutes of free monthly airtime and texts to low-income Americans. (Some programs in some states provide more minutes, some less, and some charge a small monthly fee.)
There are currently around 15 million Americans who have a free cell phone through the Lifeline program, but millions more are eligible.   
The free phones and minutes are provided by a number of national prepaid wireless companies like Safelink and Assurance Wireless, along with a host of other regional carriers throughout the country.
Many states have more than one wireless company that provide the free phones and minutes. If you are eligible, the free cell phone you’ll receive is a basic phone that also offers text messaging, voice mail, call waiting and caller ID.

To qualify, you’ll need to show that you’re receiving certain types of government benefits, such as Medicaid, Food Stamps, SSI, home energy assistance or public housing assistance. Or, that your household income is at or below 135 or 150 percent of the Federal Poverty Guidelines – it varies by state. The 135 percent poverty level is currently $15,754 for singles and $21,235 for couples. The 150 percent level is $17,505/singles, $23,595/couples.


Thursday, 17 July 2014

Insurers, providers may need to work harder to educate ACA's newly covered

Millions of Americans gained health insurance coverage under the Patient Protection and Affordable Care Act this year, but the influx apparently has not yet translated into patients packing doctors' offices. That may reflect a lack of understanding about how and where to seek care—and a lack of outreach by their new plans and providers.

“If coverage expansion is allowing patients to establish new relationships with physicians, we would expect to see physicians devote a greater share of their calendars and work effort to caring for new patients,” wrote the authors of a report released this week by the Robert Wood Johnson Foundation and Athenahealth, a company that sells cloud-based health information and practice management technology.

But that is not what they found. Though it may seem counterintuitive, the organizations discovered that during the first five months of 2014, all specialties—with the exception of pediatrics—experienced lower rates of new-patient visits than they had in the year-ago period. This was based on data taken from more than 14,000 providers across specialties.

For example, the proportion of visits from new patients to primary-care physicians in the sample from January to May 2014 was 18.8% compared with 19.3% during that same five-month period in 2013.

The study did not analyze what caused this decline, but the authors suggest that one reason is that the newly insured are continuing to go to emergency departments instead of physician offices. That explanation seems consistent with studies that showed increased emergency department use after pre-ACA expansions of health insurance in Massachusetts and Medicaid in Oregon.

“It's not unexpected at all,” said Stephen Zuckerman, co-director and a senior fellow in the Health Policy Center of the Urban Institute. “Given what we know from survey data, people are quite confused about a lot of the basic features of health insurance plans. This is true for people who have had insurance, and it's even more of an issue for people who are becoming newly insured.”

In an analysis released Tuesday, more than 80% of outreach programs surveyed by the Kaiser Family Foundation said consumers seeking their assistance didn't understand or were confused by the Affordable Care Act. And nearly three quarters of people coming to them for help had difficulty understanding basic insurance concepts, including deductibles or provider networks.

Health insurers say they have known this for a long time and have been dealing with it well before the Affordable Care Act went into effect, according to Susan Pisano, spokeswoman for the trade organization America's Health Insurance Plans.

“We as a community have been very focused on health literacy as an endeavor within the industry,” Pisano said. “But it's been amped up.”

Outreach and educational efforts from AHIP's members have included new-member kits, outbound calls to newly insured individuals, webinars, reminders for gender- and age-specific preventive coverage, and the use of multi-language materials and interpreters.

“We have been making new-member calls for as long as I can remember,” said Ed Harden, spokesman for McLaren Health Plan, based in Flint, Mich. “Every new member we enroll gets a call to welcome them to the plan and ask if they have any questions, if they've selected a primary-care physician and to coordinate scheduling an appointment for them if they need one immediately.”

McLaren also distributes newsletters, operates a website with educational information and assists members in getting enrolled in disease management programs and health counseling services.

Insurers push telehealth
Seeing a doctor may soon be a matter of a virtual visit, thanks to initiatives from big insurers that include WellPoint and Aetna. Both have begun expanding telemedicine options for their patients, offering them the opportunity to have virtual consultations with their doctors for non-urgent issues such as a sore throat or a sinus infection. “Whether Web chats or structured telephone calls, these virtual alternatives can deliver effective healthcare solutions that also help both doctors and patients save time, which makes everyone happier,” according to Hartford, Conn.-based Aetna. The insurer plans to expand online physician access to 8 million members by 2015.

Insurers seek change in medical-loss ratio rule

Insurers are putting pressure on policymakers to make changes to a rule under the Patient Protection and Affordable Care Act that they say costs the industry millions of dollars in consumer rebates each year. The medical-loss ratio rule requires that insurers spend at least 80% of revenue from premiums on healthcare costs and no more than 15% on administrative costs for large groups or 20% for small groups. If an insurer doesn't meet the ratio, they must return the difference to their consumers as a rebate. But insurers are asking that brokers' fees be removed from the calculation of administrative costs. According to a recent GAO report, excluding these fees could reduce rebates by a significant 75%. If the change had been in effect in 2011 and 2012, insurers would have returned just more than $400 million to their customers instead of $1.1 billion returned in 2011 and $520 million in 2012. "The medical-loss ratio imposes an unprecedented federal cap on health plan administrative costs that will have significant unintended consequences," a statement by America's Health Insurance Plans said. It cited reduced access to agents and brokers, increased costs, reduced efforts against fraud and abuse, and less investment in initiatives for quality and safety of patient care.


Wednesday, 16 July 2014

The Challenge of Health Care Fraud

Consumer Alert: The Impact of Health Care Fraud on You!
In 2011, $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. It is an undisputed reality that some of these health insurance claims are fraudulent. Although they constitute only a small fraction, those fraudulent claims carry a very high price tag.

The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year.

Whether you have employer-sponsored health insurance or you purchase your own insurance policy, health care fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage. For employers-private and government alike-health care fraud increases the cost of providing insurance benefits to employees and, in turn, increases the overall cost of doing business. For many Americans, the increased expense resulting from fraud could mean the difference between making health insurance a reality or not.

However, financial losses caused by health care fraud are only part of the story. Health care fraud has a human face too. Individual victims of health care fraud are sadly easy to find. These are people who are exploited and subjected to unnecessary or unsafe medical procedures. Or whose medical records are compromised or whose legitimate insurance information is used to submit falsified claims.

Don't be fooled into thinking that health care fraud is a victimless crime. There is no doubt that health care fraud can have devastating effects.

What Does Health Care Fraud Look Like?
The majority of health care fraud is committed by a very small minority of dishonest health care providers. Sadly, the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected members of our society-our physicians.

Unfortunately, the stock in trade of fraud-doers is to take advantage of the confidence that has been entrusted to them in order to commit ongoing fraud on a very broad scale. And in conceiving fraud schemes, this group has the luxury of being creative because it has access to a vast range of variables with which to conceive all sorts of wrongdoing:

·         The entire population of our nation's patients;
·         The entire range of potential medical conditions and treatments on which to base false claims; and
·         The ability to spread false billings among many insurers simultaneously, including public programs such as Medicare and Medicaid, increasing fraud proceeds while lessening their chances of being detected by any a single insurer.

The most common types of fraud committed by dishonest providers include:

·         Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
·         Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).
·         Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes.
·         Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.
·         Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
·         Unbundling - billing each step of a procedure as if it were a separate procedure.
·         Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
·         Accepting kickbacks for patient referrals.
·         Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship").

Consider Some Risks of Health Care Fraud to You


Monday, 14 July 2014


Health care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Fraudulent health care schemes come in many forms. Practitioner schemes include: individuals obtaining subsidized or fully-covered prescription pills that are actually unneeded and then selling them on the black market for a profit; billing by practitioners for care that they never rendered; filing duplicate claims for the same service rendered; altering the dates, description of services, or identities of members or providers; billing for a non-covered service as a covered service; modifying medical records; intentional incorrect reporting of diagnoses or procedures to maximize payment; use of unlicensed staff; accepting or giving kickbacks for member referrals; waiving member co-pays; and prescribing additional or unnecessary treatment. Members can commit health care fraud by providing false information when applying for programs or services, forging or selling prescription drugs, using transportation benefits for non-medical related purposes, and loaning or using another’s insurance card.

When a health care fraud is perpetrated, the health care provider passes the costs along to its customers. Because of the pervasiveness of health care fraud, statistics now show that 10 cents of every dollar spent on health care goes toward paying for fraudulent health care claims.

Congressional legislation requires that health care insurance pay a legitimate claim within 30 days. The Federal Bureau of Investigation, the U.S. Postal Service, and the Office of the Inspector General all are charged with the responsibility of investigating healthcare fraud. However, because of the 30-day rule, these agencies rarely have enough time to perform an adequate investigation before an insurer has to pay.

A successful prosecution of a health care provider that ends in a conviction can have serious consequences. The health care provider faces incarceration, fines, and possibly losing the right to practice in the medical industry.


Sunday, 13 July 2014

Health insurance rip-offs come under scrutiny

A pair of editorials last week took up the issue of Medicare and Medicaid fraud, waste and abuse, signifying these problems are becoming a greater focus of public attention and debate

"Area ambulance companies are facing deserved scrutiny for their disproportionate share of the nation's outsize[d] healthcare costs," The Inquirer wrote. Ground ambulance providers around Philadelphia collected 64 percent more Medicare dollars than the national average in 2012, with 33 area companies raking in 10 times the norm, the article noted.

"No wonder Medicare has stopped taking new company enrollments while it sorts out the fraud," the article stated.

The Inquirer referenced charges against eight local ambulance providers since 2011, including one's five-year prison sentence for executing a $3.6 million scam involving kickbacks for unnecessary transport.

"Medicare is still not as open [as] it should be," the editorial said. "It has spurned numerous attempts by The Inquirer to get additional information on the ambulance companies that are costing the government the most." The paper wants to know if aberrant providers still collect federal money and if Medicare demanded overpayment refunds.

Meanwhile, a Farmington Daily Times editorial highlighted the case of Agave Health, Inc., an Arizona mental health services company that in six months received more than $172,000 from Medicaid. Half this money was disbursed before the completion of a state audit led to a funding freeze for 15 nonprofit healthcare providers.

"The question is whether those payments suggest state officials prejudged the conclusion of the audit before it was completed," the editorial stated.

That audit exposed $36 million in Medicaid overpayments, the Times reported, which led New Mexico to halt Medicaid funding to in-state providers and shift business to Arizona companies like Agave. But New Mexico paid Agave more than it paid in-state providers. Agave billed $75 per hour for services of a family support worker, for example, while a local provider whose payments the state stopped paid workers $14.58 hourly for the same job, according to The Times.


Thursday, 10 July 2014

Suspect A Health Care Scam?

Charging you for help getting new insurance
Someone contacts you, offering to help you navigate the Health Insurance Marketplace for a fee – or saying that you need a new insurance card now or you’ll have to pay a penalty. Regardless of the set-up, their goal is to get your bank account or credit card number.

Don’t give your information. The people who offer legitimate help with the Health Insurance Marketplace – sometimes called Navigators or Assisters – are not allowed to charge you. In fact, you can’t pay them. What’s more, you don’t need to buy a special insurance card, or pay any penalties for not buying one, either. Bottom line: Never give your money or your information to anyone who contacts you.

Medicare cards
Someone gets in touch, saying you need a new Medicare card because of “Obamacare.” They tell you that you’ll lose Medicare coverage if you don’t pay a fee for a new card or give them your Social Security number and bank account or credit card number.

Not true. The Affordable Care Act doesn’t say you need a new Medicare card, or another health insurance card. Nor does the law say you’ll lose Medicare coverage. Don’t give your personal or financial information to anyone who contacts you. When in doubt, call 1-800-MEDICARE, before you give anyone your money or information.

Medical discount plans
Someone contacts you, offering discounts on health services and products. They might say the discount plan will save you money and that it meets the minimum coverage required under “Obamacare” so you won’t have to pay a penalty or look at other plans.

Medical discount plans are not health insurance. Sometimes, medical discount plans illegally pretend to be insurance. The only way to know is to ask specific questions and not pay until you read the terms. Most medical discount plans are a membership in a “club” that claims to offer reduced prices from certain doctors, certain pharmacies, and on some procedures. Many of these plans are scams that don’t deliver on the medical services promised. Others are attempts to get your personal or financial information, so the scammer can use it to commit identity fraud.

Insurance agents.
Someone claiming to be an insurance agent gets in touch to say you should “act now” to get your new insurance. They may promise to get you a special deal or help you avoid a penalty. Or they might say they can help you avoid losing access to your current doctors under Medicare – unless you sign up for a Medicare Advantage Plan.

Not true. If you have Medicare, the open enrollment for Medicare Part D and Medicare Advantage Plans stays the same: October 15 – December 7, 2013. You don’t have to do anything different because of the Affordable Care Act. While some insurance agents can help you with your application through the Health Insurance Marketplace, don’t give your personal information or pay any money to someone who contacts you.

“I can help you. Really.”
Someone contacts you, offering to help you navigate the Health Insurance Marketplace. There really are trained people who can help. But experts expect scammers to wade in here, too. So…  

See what they do. The helpers might be called navigators, assistors, counselors, connectors, or something similar. The important thing is what they do. The official helpers will try to help you find the plan that serves you best. If you want, they might help you get signed up through HealthCare.gov. They will not try to sell you a particular plan or ask for money to help you. If someone does that, chances are they’re not an official trained helper.

“I’m from the government.”
No. They’re not. The government will not call you about your health insurance; and no one from the government will ask you to verify your Social Security number or bank information. Some government agencies might send you a letter (for example, Medicare and the IRS), but they will never ask you to wire them money or give your credit card number. If someone calls, emails, or texts and says they’re from the government, it’s a scam.

Report any scams you see.
Call 1-877-FTC-HELP (1-877-382-4357) or go to ftc.gov/complaint. Your reports give the FTC the information it needs to launch investigations, and put scammers out of business.

If you’re shopping in the Health Insurance Marketplace, do it at HealthCare.gov. People who try to sign you up elsewhere just might be scamming you.


Wednesday, 9 July 2014

Senate Dems Try to Pull Focus From Health Law

Thom Tillis is stuck at the state capitol trying to resolve a budget quarrel as speaker of the North Carolina House. It's a spot that helps Hagan emphasize Tillis' role leading a Republican-controlled state government that Democrats contend has gone overboard with conservative zeal by restricting access to abortion and the voting booth while cutting corporate taxes and slashing spending on schools. (Hagan, the daughter of Joe P. Ruthven, grew up in Lakeland.)

If Tillis is worried by Hagan's portrayal, he doesn't show it. Drinking coffee last week from a hand-grenade-shaped mug in his no-frills legislative office, he's got his own message in his campaign to take Hagan's Senate seat. "Obamacare," he said, "continues to be a big problem." Similar themes are playing out in other crucial Senate races, as voters have four months to decide which party will control the chamber in the final two years of Barack Obama's presidency.

For Republicans, it's all about tying Democrats to Obama — especially to a health care law that remains unpopular with many Americans. And for Democrats, the election is about just about anything else, especially if they can steer attention away from Washington and federal matters.

It's a political strategy that sometimes gives the campaigns an inside-out feel, with veteran senators running as if they were first-timers without a Washington resume to defend or tout.


Tuesday, 8 July 2014

Steer clear of health insurance scams

How to spot and stop health insurance scams
Medical and health insurance scams are rampant. Both government and private initiatives have renewed their focus on preventing health insurance fraud and abuse. Michael Williams, director of communications and membership of the National Health Care Anti-Fraud Association, says new and better technology, improved awareness, and more widely available information combine to combat fraud. Williams adds that while the majority of physicians run honest practices, consumers must also step up to the plate to prevent fraud.
"Pay attention, do your research, read your EOBs (explanations of benefits) and beware of free offers," he says.
Read on to discover some of the most common health insurance scams making the rounds and ways experts like Williams say you can guard against becoming another victim.

Fake insurance policies
Like counterfeit money, bogus health insurance is not only circulating, but it's becoming increasingly common. James Quiggle, communications director of the Coalition Against Insurance Fraud, says fake policies are particularly virulent.
"These crooks come out of the woodwork and promise affordable premiums, no medical exams and guaranteed acceptance," Quiggle says, adding that the criminals who offer worthless policies often operate through sophisticated networks with strong marketing arms and money-laundering components. Many times they can be tied to organized crime.

Often, these con artists target small businesses, unions and associations. It's only when a policyholder needs the insurance that the game's up.

How to spot the scam: Use common sense, says Quiggle. Check with your state's department of insurance to see if the company is properly licensed. And remember, if it seems too good to be true, it most likely is.

What to do: If your policy is through an organization, report fraud to someone within the organization. Also, report the fraud to the Federal Trade Commission at FTC.gov and your state's department of insurance.

Bogus Obamacare policies
With the phased-in implementation of the Patient Protection and Affordable Care Act, known more commonly as Obamacare, hucksters by the thousands have surfaced. Reports of program-related scams have flooded in from all over the country, according to Thomas M. Devlin, chief deputy attorney general for the Health Care section of the Pennsylvania Attorney General's office.One prominent health insurance scam involves the criminals calling victims and trying to con them out of personal information.

"They're trying to tell people they're going to be issued a national health card and they need their Social Security numbers and bank account numbers; essentially, it's an identity theft type of scam," Devlin says.

"Be aware that the government is not going to solicit information over the phone or through email," he warns.

How to spot the scam: Any effort to solicit information from you for national health care should be regarded as suspicious. Don't respond to emails, and hang up on the callers.

What to do: Report your complaint to the Federal Trade Commission.

Medicare and Medicaid fraud
The Coalition Against Insurance Fraud says that in 2007 alone, Medicare and Medicaid made an estimated $23.7 billion in improper payments. Medicare accounted for $10.8 billion of that amount. However, as baby boomers get older, the number of seniors joining the program is expected to grow, so those numbers are expected to rapidly expand.

Jeff Young, vice president of fraud control at Verisk Health, says Medicare and Medicaid fraud generally begin at a practitioner's office. The staff members may order tests the patient's condition doesn't warrant, "upcode" or falsify what procedure the patient receives, or bill for nonexistent hours -- "double bill" -- among other illegal practices.

Although these don't necessarily impact the patient out of pocket, it can come back to haunt patients who really do need a medical procedure at some future point, and who could be denied the service based on false evidence. And, of course, there is also the moral issue of ripping off taxpayers.

"Ask questions as a consumer: 'Why do I need this (procedure)?' Get the answers upfront," says Young.

How to spot the scam: While explanations of benefits, or EOBs, can be complicated,  always read through them.

What to do: If you spot an error, contact your insurer, either Medicare or Medicaid.

Medical discount card scams
A few years ago, the state of California joined Massachusetts in taking on the sellers of unscrupulous medical discount cards. Presented as a substitute for health insurance or a way to obtain discounts for everything from eye exams to dental work, the cards target mostly poor communities and are often useless. Experts say they expect to see more of these offers in the future.

These cards provide fake lists of providers, phony discounts, and high fees that aren't readily apparent and often mimic health insurance but provide no actual benefits. Ads for them can be found all over the Internet and in print and televised media. Dr. Deborah C. Peel, a physician and founder of the nonprofit Patient Privacy Rights, says beware when those selling such cards try and get you to divulge personal information, like your Social Security number.

"Always question why someone needs that information," Peel warns.

How to spot the scam: If you find a discount card you like, research it. If you discover complaints, hidden fees, false or overblown promises, or exorbitant costs, run fast in the opposite direction.

What to do: If you've already signed on with a company that's sold you a bogus discount card, contact your local state department of insurance.

Employers without workers' comp
Most workers don't think about having workers' compensation insurance until they need it, but an on-the-job injury could leave them in a financial bind. And, some employers don't carry workers' compensation coverage even though they are mandated to do so by law. This year, North Carolina state auditor Beth Wood reported that more than 11,000 businesses in her state canceled coverage or let it lapse. That meant about 30,000 employers required to carry workers' compensation insurance were without it.

Quiggle says lack of workers' compensation coverage is particularly rampant in certain industries, such as construction.

"When a worker falls off the roof and wakes up in the hospital, he ends up finding he's not covered by workers' comp," Quiggle says. It's a rude awakening to a health insurance scam in which the employer is the culprit.

How to spot the scam: Your employer should be happy to provide copies of its policies and procedures for on-the-job injuries. If it hasn't or if another worker has an accident and finds he or she isn't covered, then you probably aren't covered, either.

What to do: Report this health insurance scam to your state department of insurance.