Healthcare Reform and the New Opportunities for the Ethically [PDF]

SLIDE 1

Healthcare Reform and the New Opportunities for the Ethically Challenged

May 21, 2009

Rebecca S. Busch, RN, MBA, CFE, CCM, CBM, FIALCP, FHFMA

CEO, Medical Business Associates 580 Oakmont Lane, Westmont IL 60559 www.mbanews.com info@mbanews.com 630.789.9000

Webinar Agenda

Fraud: key initiative in healthcare reform
Global Perspective on Fraud & Fraud Concepts in

Healthcare

Profiling Fraud
Review Critical Schemes
Review Latest Fraud Issues
Who Gets Hurt?
Trigger Points

SLIDE 2

Polling Question #1

How many people in the audience:

– Work for hospitals? – Work for insurance companies – Work for a government agency or law enforcement – Are not in healthcare and just want to learn more about the topic?

Polling Question #2

Are you are actively involved in healthcare fraud related

work?

– Yes – No

SLIDE 3

Polling Question #3

Have you ever worked directly with a individual consumer

that was a fraud victim?

– Yes – No

Polling Question #4

Have you ever been a victim of healthcare fraud in any

form?

– Yes – No

SLIDE 4

FRAUD – Technical Definition

Misrepresentation of a material fact consisting of a false

representation, concealment or non-disclosure;

Knowledge of the falsity
Intent to deceive and induce reliance;
Justifiable and actual reliance on the misrepresentation; and
Resulting damages.

FRAUD – On the front line

“Things” or “Events” that hurt people
Affecting ones person, home, family, assets, and community
Resulting in disability, financial devastation, loss of loved ones,

and death

Leaving a person with a loss of faith, hope, trust, and sense of

identity

SLIDE 5

WHY AN ISSUE?

2 TRILLION DOLLAR Industry
OIG ROI ON AUDITS/INVESTIGATION $17 TO $1
Estimated that $60 billion annually goes to fraud

Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf

OIG areas of concern

Payments for unallowable services
Improper services not rendered
Improper claims submissions
Medicare reimbursement rates are too high for certain services.
Payments for inadequately documented services
Manipulation of billing systems
Inaccurate wage data
Manipulative gaming through discharge or transfer of patients to

facilities for financial versus clinical reason.

Unreasonable and not medically necessary services

Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf

SLIDE 6

OIG Identified Vulnerabilities

DME suppliers circumventing enrollment and billing

controls

High levels of improper Medicare payment for

certain types of DME, prosthetics, orthotics, and supplies (DMEPOS);

Inappropriate reimbursement rate for certain

DMEPOS.

Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf

5 Principals of Effective Anti Fraud Activity

1. Scrutinize individuals and entities that want to participate as

providers and suppliers prior to their enrollment in health care programs.

2. Establish payment methodologies that are reasonable and

responsive to change in the market place.

3. Assist health care providers and supplier in adopting practices

that promote compliance with program requirements, including quality and safety standards.

4. Vigilantly monitor the programs for evidence of fraud, waste,

and abuse.

5. Respond swiftly to detected frauds, impose sufficient

punishment to deter others, and promptly remedy program vulnerabilities.

Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf

SLIDE 7

Global Perspective

Primary Healthcare Continuum
Secondary Healthcare Continuum
Information Continuum
Consequence Continuum
Transparency Continuum

Primary Health Care Continuum (“P-HCC”): Clinical, Service, Product, and Financial Integration

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SLIDE 8

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SLIDE 11

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Decision Making Ladder for Pharmaceuticals

SLIDE 12

Data Driven Decision Making – RX Example

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Anomaly Data Analysis Profiler

Table 9: FRAUD PROFILER

SLIDE 13

Fraud Issues

Medical Identity Theft
Illicit Provider Rx Sales
Illicit Internet Rx Sales
Drug Diversion, Adulterated Drugs
Counterfeit Drug Activity
Theft of limited Resources (medically unnecessary

services)

Fraud Issues

Vulnerable Patients – Neglect & Abuse
Patient Experimentation
Off Label Medication Use
Provider False Claim
Foreign Nationals Shopping Health Dollars in US
Vendor/TPA Fraud

SLIDE 14

Medical Identity Theft

MIT is the theft of IIHI for the purpose of misrepresentation of health information

to obtain access to property or permanently deprive or harm an individual while interacting within the healthcare continuum. Use of an individual’s identity

utside the healthcare continuum is considered identity theft.
When a perpetrator steals all or part of the IIHI elements from a medical record

file to open up a credit card account and go on a shopping spree, it is considered identity theft—not medical identity theft. The differentiating factor for medical identity theft is that the stolen information is used for illegal gains within the healthcare domain

Medical Identity Theft

Katrina Brookes. Ms. Brookes started receiving healthcare bills in the name
f her son, which included his middle name.
At this point no one knew her child’s middle name except close family and

the hospital in which she completed paperwork to obtain her son’s social security number.

The new paperwork was not placed within her son’s medical record. New

bills started to arrive from other providers.

The mother was suspicious because how could any other new provider

know of her sons’ middle name since she had not shared it with anyone else?

SLIDE 15

Medical Identity Theft

Again, the breach occurred during a nontraditional health service in the

healthcare setting.

Any one can be a victim, the elderly, the sick, or the unsuspecting.
When it comes to children, however, many of them will not know that their

identity has been breached until the age at which they are able to secure credit.

With respect to health services, the child will be dependent on the adult to

ensure that future providers are not responding to adulterated records.

These examples illustrate exposure to financial issues and medical errors issues, but

how about losing your children? [i] http://www.msnbc.msn.com/id/23392229.

Medical Identity Theft

Anndorie Sachs, from Salt Lake City and mother of four children, provides

an unimaginable consequence of MIT. Her experience dates back to April 2006, when she was approached by a Utah social worker.

The plan was to take away her children. The last time Ms. Sachs had given

birth to a child was in 2004. The problem was that Dorothy Bell Moran, a known meth user, gave birth with Ms. Sachs identification [at the hospital. Social Services wanted to take away Ms. Sachs children because they thought she just delivered a baby with meth in her blood stream.

After repeated phone calls for clarification Ms. Sachs was able to prove that
Ms. Moran delivered the baby with meth in her blood stream.

SLIDE 16

Medical Identity Theft

Ms. Sachs was then allowed to keep her children. Further

consequences were noted when Ms. Sachs was later admitted into a different hospital with a kidney infection. The next issue involved Ms. Morans health records were not integrated into Ms. Sachs record.

A critical issue occurred in the Ms. Sachs her blood type is different

from Ms. Morans, thus creating an opportunity for Ms. Sachs to be subjected to a medical error due to incorrect information. [1]

[1] http://www.msnbc.msn.com/id/23392229.

Medical Identity Theft

Theft of individually identifiable information (IIHI) Inappropriate and unauthorized use within the healthcare continuum Misrepresentations within the HCC may result in false claims; theft of health services from plan sponsor, false research, false public health reports etc. Corrupted health records can Lead Risk to Health, safety & life of patient Primary Healthcare Continuum (P-HCC) patient, provider, payer, plan sponsor, support vendors Secondary Healthcare Continuum (S-HCC) Reporting Agencies, Research, Public Health, Law enforcement etc. and support vendors Inappropriate and unauthorized use outside the healthcare continuum Identity Theft & Other Criminal Activity

SLIDE 17

Identity Theft within S-HCC

“HAROLD MCCOY; ET AL (PHILADELPHIA):

On June 16, 2006, Harold McCoy was sentenced to 162 months in prison following a guilty plea to charges of bank fraud, identity theft, and conspiracy for his role in a scheme to defraud numerous American Red Cross (ARC) blood donors in the Philadelphia area.

McCoy obtained the names and personal identifying information of numerous blood

donors from an employee of ARC. He and his co-conspirators, Karynn Long and Danielle Baker, then used the stolen information to obtain instant credit loans, bank loans, and to cash counterfeit checks, causing approximately $800,000 in losses to various financial institutions.

Identity Theft within S-HCC

This crime jeopardized the Philadelphia area blood supply and damaged ARC's

trusted relationship with the public, as many people stopped donating blood and two corporate donation centers ceased their blood drives when the media reported the crime.

For their roles in this scheme, Long pled guilty to bank fraud and conspiracy and was

sentenced to 18 months in prison; Baker pled guilty to identity theft and conspiracy and was sentenced to 24 months in prison. All three defendants were ordered to pay restitution in the amount of $270,555.” [1]

[1] http://www.fbi.gov/publications/financial/fcs_report2006/financial_crime_2006.htm

SLIDE 18

What Else?....Rx Providers

“JORGE A. MARTINEZ, M.D. (CLEVELAND):

This investigation resulted in the first known prosecution involving a criminal charge of Health Care Fraud resulting in death.

The case focused on the illegal distribution of pharmaceutical narcotics and billing

for unnecessary medical procedures.

The investigation revealed that Dr. Martinez provided excessive narcotic

prescriptions, including Oxycontin, to patients in exchange for the patients enduring unnecessary nerve block injections. Dr. Martinez’ actions directly resulted in the death of two of his patients. From 1998 until his arrest in 2004, Martinez submitted more than $59 million in claims to Medicare, Medicaid, and the Ohio Bureau of Worker's Compensation.

What Else?....Rx Providers

In January 2006, a jury found Martinez guilty of 56 criminal counts,

including distribution of controlled substances, mail fraud, wire fraud, Health Care Fraud, and Health Care Fraud resulting in death. Martinez was later sentenced to life in prison.

This investigation was conducted jointly with the HHS-OIG, Ohio Bureau of

Workers Compensation, DEA Diversion, AdvanceMed, Ohio Department of

Job and Family Services, Anthem Blue Cross Blue Shield and Medical Mutual of Ohio.”[1]

[1] http://www.fbi.gov/publications/financial/fcs_report2006/financial_crime_2006.htm

SLIDE 19

What Else?...Drugs

BANSAL ORGANIZATION (PHILADELPHIA):

This investigation was conducted jointly with the DEA and IRS and was focused on a Philadelphia-based Internet pharmacy drug distributor which was smuggling drugs into the U.S. from India and selling them over the Internet.

The criminal organization shipped several thousand packages per week to

individuals around the country. In April 2005, 24 individuals were indicted

n charges of distributing controlled substances, importing controlled

substances, involvement in a continuing criminal enterprise, introducing misbranded drugs into interstate commerce, and participating in money

laundering. Over $8 million has been seized to date as a result of the

charges.

What Else?...Drugs

As of December 1, 2006, 12 suspects have pled guilty, three have been

convicted at trial, four are in foreign custody, and five remain fugitives. This investigation was worked jointly with the DEA, IRS, ICE, USPIS, and the Lower Merion Police Department. [i]

[i] http://www.fbi.gov/publications/financial/fcs_report2006/financial_crime_2006.htm.

SLIDE 20

Dangerous Doses

Operation Stone Cold Florida counterfeit ring
Charges charged with trafficking in bad medicine – indicted in 2003 on

charges of racketeering, conspiracy to commit racketeering, organized scheme to defraud, grand theft, dealing in stolen property, sale or delivery of a controlled substance, possession with intent to sell prescription drugs, sale and delivery of a controlled substance and purchase or receipt of a prescription drug from an authorized person.

Perpetrators

Michael Carlow – ex-convict
Candace Carlow, wife
Thomas Atkins, brother in law
Marilyn Atkins, mother in law
Jose L. Benitez, business partner
14 other parties
$42 million dollar enterprise

SLIDE 21

Profile of one victim

Timothy Fagan
16 years of age
Receive a successful live transplant
Mom injecting Epogen at home once per week
Timothy experienced excruciating pain
Mom checks in with Doc – receives notice of counterfeit Epogen

How did this happen?

Investigation found that no chain of custody exists once

the drug leaves the manufacturer.

Drugs lost in the secondary wholesaler market
Anyone can apply for a license

SLIDE 22

Amgen Drugmaker 2,000 U/ml Cardinal 8,931 boxes 2,000 U/ml AmerisourceBergen 3,363 boxes 2,000 U/ml J& M Pharmacare FL Pharmacy Bought 12,294 boxes 2,000 U/ml Armando Rodriguez FL Go-Between 12,294 boxes 2,000 U/ml Jose Grillo Alleged FL Counterfeiter 2,000 U/ml → 40,000 U/ml Silvino Morales Relabeled Vials Printer in Hialeah Made Counterfeit Labels Playpen South FL Strip Club Nick Just/Paul Perito Double J Unlicensed FL Wholesaler Costal Medical VA Wholesaler 135 Boxes Lot 2970 Tradewinds Trading TX Wholesaler 135 boxes Lot 2970 Rebel Dist CA Wholesaler Grapevine Trading OH Wholesaler AD Pharmaceutical FL Wholesaler 2 boxes Lot 2970 Medix Intl Carlos Luis TX Shell Co. 180 Boxes Lot 2970 Y W Consultants Unlicensed FL Wholesaler Ivan Villarchao FL 45 Boxes Lot 2970 Armin Medical NH Wholesaler 129 Boxes Lot 2970 Express RX Eddie Mor TX Shell Co. 180 Boxes Lot 2970 Premier Medical Group GA Shell Co. 460 Boxes Lot 1091 812 Boxes Lot 2970 Optia Medical Mark Novosel UT Shell Co. 45 Boxes Lot 2970 Jemco Medical FL Wholesaler 16 Boxes Lot 2970 AmeRx Susan Cavalieri FL Wholesaler 182 Boxes Lot 2970 CSG TN Wholesaler 460 Boxes Lot 1091 CSG TN Wholesaler 812 Boxes Lot 2970 Dialysist West AZ Wholesaler 1056 Boxes, Lot 2970 Dialysist West AZ Wholesaler 461 Boxes, Lot 1091 AmerisourceBergen KY Distribution Center 1517 Boxes CVS, NY Timothy Fagen

-- probable sales

unknown sources and sales → confirmed sales

Manufacturer National Wholesaler Gray Market Regional Wholesaler National Wholesaler Pharmacy Patient

Jury Convicts Miami Physician and Nurse of $11 Million HIV Infusion Medicare Fraud

Miami physician Ana Alvarez-Jacinto, 54, and nurse Sandra Mateos, 43, were

found guilty by a Miami jury for their roles in an $11 million HIV/AIDS infusion fraud scheme.

Evidence at trial established that both defendants worked at Saint Jude Rehab

Center Inc. ( St. Jude ), a clinic that purported to specialize in treating HIV/AIDS patients. St. Jude was operated and owned by indicted fugitives Carlos Benitez and Luis Benitez, and managed by convicted co-conspirators Aisa Perera and Mariela Rodriguez.

SLIDE 23

Jury Convicts Miami Physician and Nurse of $11 Million HIV Infusion Medicare Fraud

Evidence at trial proved that between June and November 2003, Alvarez-

Jacinto, with the assistance Mateos, ordered hundreds of medically unnecessary HIV infusion treatments at the clinic.

Evidence at trial also established that HIV-positive Medicare patients were

brought to the clinic by Carlos and Luis Benitez for the purpose of getting cash payments in exchange for allowing the clinic to bill for unnecessary treatments.

Jury Convicts Miami Physician and Nurse of $11 Million HIV Infusion Medicare Fraud

Testimony at trial revealed that defendant Mateos and other co-conspirators

paid the patients cash kickbacks of approximately $150 per visit.

After patients had been paid, they agreed to allow Alvarez-Jacinto and her co-

conspirators to prescribe, and sometimes administer, unnecessary infusion treatments.

According to testimony at trial, St. Jude then billed Medicare for approximately

$11 million for the unnecessary services. For those claims, Medicare paid more than $8 million to St. Jude.

SLIDE 24

WHO GETS HURT?

HIV (Human immunodeficiency virus) primarily infects vital cells in the

human immune system

AIDS (Acquired immune deficiency syndrome) the progression of

disease

These individuals mostly die from opportunistic infections or

malignancies associated with the progressive failure of the immune system

WHO GETS HURT?

The aim of antiretroviral treatment is to keep the amount of

HIV in the body at a low level. This stops any weakening

f the immune system and allows it to recover from any

damage that HIV might have caused already.

AIDS can attack cells in the immune system for example

Platelets: Cells that help the blood to clot.

SLIDE 25

WHO GETS HURT?

$11 million dollars stolen
$1,000 per infusion
11,000 patients (2.3%)
At the end of 2007, the estimated number of persons

living with AIDS in the United States and dependent areas was 468,578

March 2009 Arrest in Florida

Two Miami-area residents pleaded guilty today in

connection with a $10 million Medicare fraud scheme involving HIV infusion clinics

$11 million dollars stolen
$1,000 per infusion
10,000 patients

SLIDE 26

March 2009 Arrest in Florida

To make it appear that the patients actually had low

platelet levels, Del Cueto admitted that she and her co- conspirators used chemists, including Dagnesses, to manipulate the blood samples drawn from Midway's patients before the blood was sent to a laboratory for analysis.

More IV infusion Cases

November 2004, brothers Carlos and Luis Benitez conspired to submit

about $110 million in false claims to the Medicare program for HIV infusion services. 110,000 patients neglected

Garcia faces a maximum of 85 years in prison. Freire faces a

maximum of 65 years in prison if convicted on all charges for $56

million. 56,000 patients neglected.

SLIDE 27

The Numbers Tell the Story

Just 4 Cases Alone
187,000 Patients
40% of Patient Living in the US with HIV/AIDS

Trigger Points: DATA

Data – Volume of claims by provider
Reconciliation of infusion claims with laboratory tests, CMS-

1500 Data, UB-92 Data

Address association, vendor trending, billing agent trending,

supply trending

Clinical data analysis
CDC Statistics on Occurrences

SLIDE 28

Nursing Home Owner Convicted in Bedpan Death

February 2009 The owner of a nursing home in Albuquerque, New Mexico,

has been found guilty of felony abuse and neglect in connection to charges stemming from an incident on Christmas day in 2005.

As reported by Andrews Publications, Richard Gerhardt, a 76-year-old

resident at the nursing home, who was recovering from a broken hip, was placed on a bed pan and left there for 24 hours.

According to reports, the bedpan became imbedded in his skin, causing an
pen wound that became infected and resulted in his death 5 days later.

Who Gets Hurt?

Vulnerable population – Elderly

SLIDE 29

The Number Tells the Story

In 2004, about 159,000 current U.S. nursing home residents

(11%) had pressure ulcers. Stage 2 pressure ulcers were the most common. (CDC)

15,281 Nursing Homes in US
1,368,230 Nursing Home residents
92.3% with deficiencies
9.7% with no deficiencies
17.6% with serious deficiencies

Trigger Points: Top 10 Issues

Accident Environment 37%
Food Sanitation 35%
Quality of Care 29%
Professional Standards 28%
Comprehensive Care Plans 22%

SLIDE 30

Trigger Points: Top 10 Issues

Housekeeping 20%
Incontinence/Urinary Care 19%
Pressure Sores 19%
Unnecessary Drugs 19%
Infection Control 18%

Doctor experimented on patients, suit alleges February 2009

A whistleblower complaint accuses former osteopathic surgeon Dr. John A.

King of experimenting on 26 of his patients.

The federal complaint says King used medical devices in ways that hadn't

been approved by the FDA and received illegal kickbacks for doing it.

"King and David McNair [King's physician assistant] were conducting clinical

research and human patient experimentation when they performed the anterior lumbar inter-body fusions" on eight patients, the "qui tam," or whistleblower, complaint states.

"King and McNair took studies that failed in laboratory animals, and then,

without any reasonable basis to conclude that they would be successful, began to experiment on humans," the complaint says.

King generated 124 medical malpractice lawsuits during his short tenure at

Putnam General Hospital between November 2002 and June 2003.

SLIDE 31

Doctor experimented on patients, suit alleges February 2009

He's lost his medical license in numerous states, including West
Virginia. Putnam General's former owner, Hospital Corporation of

America, has paid out approximately $100 million to settle King- generated lawsuits.

These new charges against King are contained in a previously sealed

whistleblower complaint filed against EBI Inc. on May 12, 2006, in federal court in Charleston.

Doctor experimented on patients, suit alleges February 2009

Along with King and McNair, the complaint targets two companies:
Wright Medical Technology Inc. based in Arlington, Tenn., made Allomatrix, a

bone fusion material that failed to work properly during two experimental studies performed on rats and rabbits. A third study, using pig-tailed macaques, rare primates native to Southeast Asia, showed "questionable" benefits.

EBI Inc., a subsidiary of Biomet Inc. in Parsippany, N.J., made spine

stimulating devices King used during his surgeries. EBI allegedly paid King a bonus each time he inserted one of their "Ionic Spacers" into a patient's spine.

SLIDE 32

Doctor experimented on patients, suit alleges February 2009

No consent, no review
According to the complaint, King and McNair undertook deliberate, well-

planned experiments on these patients.

For example, they allegedly made sure half the patients were male and

half female. They implanted 12 patients with one type of device, and 14 patients with another.

Despite this, patients say they were never informed they would receive an

experimental device.

Doctor experimented on patients, suit alleges February 2009

"If any patients were to have been participants by design in an experimental

protocol such as that conducted by King and McNair, appropriate informed consents would have to have been obtained from the patients," the complaint states.

There is no evidence patients were asked to sign a consent form.
"Additionally, institutional review board approval would have had to have been

granted by the hospital where the clinical study was undertaken" and all procedures "approved by the research committee of the medical center."

Those procedures were never followed at Putnam General.
EBI was fully aware of what King was doing at that time, the qui tam complaint

alleges.

SLIDE 33

Who Gets Hurt?

The Patient 30 Plus people and their families

Trigger Points

Data Statistical Sampling of Occurrence
Data – Volume of claims by provider
Reconciliation of infusion claims with laboratory tests, CMS-1500 Data,

UB-92 Data

Address association, vendor trending, billing agent trending, supply

$425 Million Cephalon Civil Settlement and Criminal Fine;

In America's Largest

Biotechnology Medicaid Fraud Case; Qui Tam Whistleblower

Attorney Brian P. Kenney, Esq. Filed First Complaint With

Client's Off-Label Marketing Allegations In 2003;

$375 Million Civil Settlement, $50 Million Corporate

Criminal Fine Today

$425 Million Cephalon Civil Settlement and Criminal Fine;

Many Schemes:

– Intensively marketing Actq to physical medicine and rehabilitation, and pain management specialists; – Encouraging sales reps to make false statements about the efficacy of Gabatril, and providing dosing recommendations when none have been determined for depression; – Leaving "huge doses of Gabatril" with psychiatrists when no approved use

r dosage existed for psychiatrists;

– Encouraging sales representatives to recruit psychiatrists by paying the physicians honoraria in return for recommending Gabatril to other psychiatrists; and – Assisting physicians in securing Medicaid reimbursement for Actiq when

ff-label use was ineligible for Medicaid payment.

SLIDE 35

Who Gets Hurt?

Studies have shown the off label use can generate more adverse drug

reactions

Significant number of studies in off label use with children –

specifically psychotropic medications

Market Dilemma: The FDA has stated: 1 and the American Medical

Association agrees; 2 that physicians are free to prescribe approved drugs for any scientifically supported use, whether on- or off-label.

Trigger Points

Scientifically valid studies
Marketing materials
CDC occurrence analysis by diagnosis and prescription

medication

SLIDE 36

Worldwide injunction granted against American living in B.C.

Thursday, October 23, 2008 Vancouver - A B.C. Supreme

Court judge has granted a worldwide injunction to freeze the cash and assets of an American man who has been living in Vancouver for two years and is wanted in the U.S. for a $54-million US Medicare fraud.

Worldwide injunction granted against American living in B.C.

Peter G. Rogan, 62, formerly of Valparaiso, Ind., was detained May 25

by the Canada Border Services Agency when returning to Vancouver from a trip to China.

Paula Faber of the Immigration and Refugee Board in Vancouver said

Rogan was detained by the CBSA for "serious criminality" but was released June 3 on terms and conditions after an IRB hearing.

SLIDE 37

Worldwide injunction granted against American living in B.C.

Rogan sold Edgewater Hospital but continued to control it and medical center

through various management companies he owned, U.S. authorities say.

The hospital closed in December 2001 and entered bankruptcy in 2002, when

four doctors, a vice president and the management company pleaded guilty to federal criminal health-care fraud charges involving the payment of kickbacks for patient referrals and medically unnecessary hospital admissions, tests, and services.

In September 2006, following a trial, U.S. District Court Judge John Darrah

entered a judgment against Rogan for $64,259,032

Who Gets Hurt

331 hospital beds
2002 Average 183 patients per hospital bed
607,702 potential victims – one facility

SLIDE 38

Trigger Points for Fraud

Data Statistical Sampling of Occurrence
Data – Volume of claims by provider
Reconciliation of infusion claims with laboratory tests, CMS-1500 Data,

UB-92 Data

Address association, vendor trending, billing agent trending, supply

POA codes

Freeport doctor sentenced for health care fraud 2009

Dr. Robert L. Ignasiak Jr. was sentenced today by Senior

U.S. District Judge Lacey A. Collier to 292 months in prison, fined $1 million, and ordered to pay an additional $4,300 Special Monetary Assessment.

SLIDE 39

Freeport doctor sentenced for health care fraud 2009

Ignasiak was found guilty on Nov. 3, 2008, of 43 charges including:

health care fraud; dispensing controlled substances, including fentanyl, hydrocodone, diazepam, chlonazepam, morphine, and alprazolam, the use of which resulted in the death of two persons; and unlawfully dispensing controlled substances, including oxycodone, morphine, fentanyl, hydrocodone, alprazolam, diazepam, clonazepam and carisoprodol,

Freeport doctor sentenced for health care fraud 2009

evidence that Ignasiak prescribed controlled substances to patients

knowing the patients were addicted to the substances, misusing the substances, or were "doctor shopping," and were requesting additional quantities of controlled substances for their drug habits.

Ignasiak attracted patients from across the Southeastern United

States because of his willingness to prescribe controlled substances with little or no medical justification

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Freeport doctor sentenced for health care fraud 2009

nearly all of his patients were prescribed controlled

substances, even though he claimed to be a family practitioner with no specialty in pain management or in psychiatric medications.

Who Gets Hurt?

Active Addict
Future Addicts
Family members of addicts
The patient – disability death
Lost resources for legitimate patients

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Trigger Points:

Data Statistical Sampling of Occurrence
Data – Volume of claims by provider
Reconciliation of infusion claims with laboratory tests, CMS-1500 Data,

UB-92 Data

Address association, vendor trending, billing agent trending, supply

Admitting Diagnosis,

'Humanitarian' gets prison term in Medicaid fraud

Melee Kermue, 32, pleaded guilty in October to a scheme in which his

Reynoldsburg-based health-care business submitted an estimated 4,800 fraudulent claims to the Ohio Medicaid program.

Must repay the $272,525 in claims as part of his sentence
He came to Ohio in 1997, earned an associate degree and founded Hope

Home Health Care Inc., which provided skilled nursing to Medicaid patients in their homes.

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'Humanitarian' gets prison term in Medicaid fraud

Federal prosecutors said the company submitted claims to Medicaid that

included false names and dates of service and claims for services provided by hospitals, not in clients' homes.

Kermue deserved leniency, his attorney, Jeremy Dodgion, said, because he

returned to the U.S. on his own to face the charges and has lived as a respected politician and humanitarian in Liberia. A nonprofit organization he

perated in the western African nation provided housing for 450 people and

medical supplies to refugees

Fraud for profit or philanthropy?

Who Gets Hurt?

2,725 – 3,633 Ohio Medicaid Patients

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AmeriChoice of Pennsylvania, Inc. has agreed to pay $1.6 million

Enter into a corporate integrity agreement
Agreed to maintain a claims processing system that will allow providers to

query the status of unsettled claims, to settle allegations by the U.S. Attorney for the Eastern District of Pennsylvania and the HHS OIG that the company violated the False Claims Act.

The settlement requires AmeriChoice to pay 95% of clean claims within thirty

days of receiving all necessary documentation to process the claim.

The government alleged that from September 1995 through June 1998,

AmeriChoice did not pay providers' health claims in a timely fashion or did not pay them at all.

They did not answer recipient call, altered CPT codes, and other issues

related to performance guarantee data

The complaint also alleged that the company did not report claims processing

data accurately to regulators. AmeriChoice, previously known as Healthcare Management Alternatives Inc.

Who Gets Hurt?

The patient/beneficiary
The integrity of the program

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Trigger Points

Hot line beneficiary complaints
Provider complaints
Excessive denials
Performance Guarantee Reports

Who Gets Hurt?

You
303,824,640 US citizens
832 potential victims on a daily basis
6,706,993,152 World Population
18,375 potential victim on a daily basis

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QUESTIONS?

Rebecca S. Busch bbusch@mbanews.com 630.789.9000

Healthcare Reform and the New Opportunities for the Ethically Challenged Thank you

Rebecca S. Busch, RN, CFE, MBA, CCM, CBM, FIALCP, FHFMA CEO, Medical Business Associates bbusch@mbanews.com 630.789.9000