@IIAChicago #IIACHI Healthcare Reform & The Ethically ... Seminar Presentations/B2... · Playpen...
Transcript of @IIAChicago #IIACHI Healthcare Reform & The Ethically ... Seminar Presentations/B2... · Playpen...
IIA Chicago Chapter 53rd Annual Seminar April 15, 2013, Donald E. Stephens Convention Center
@IIAChicago #IIACHI
Healthcare Reform & The Ethically Challenged
Managing Transformation
Rebecca S. Busch, RN, MBA, CCM, CFE, CPC, CHS-III, CRMA, CICA, FIALCP, FHFMA CEO, Medical Business Associates, Inc. www.mbaaudit.com
Overview
• ACA & Healthcare Fraud • Organized Crime & Business Diversification • General Auditor Overview • General Auditor Checklist • Sample Schemes
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ACA
• More money to prevent and fight fraud • Better screening and compliance • New penalties • Better data sharing • Section 6401 has specific compliance
provisions
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ACA – Focus Areas
• DME • Home Health • Hospice • Medicare Advantage • Nursing Home
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Organized Crime
• Criminal activity carried out by an organized enterprise
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Evolving Fraud Schemes…
Group Health Fraud Financial Crimes
Property & Casualty, Other Insurance
The Anatomy of the Ethically Challenged – Business Diversification Perspective
Any Party Insured Parties
Identities, Bank Accounts, Assets
Bodies, Coverage Plan, Victims, Perpetrators
False Claims, Medical Identity Theft, Pharmacy Mischief…
Identity Theft , Embezzlement, Behaviors…
Accident Rings/Fraud Rings…
Medicare, Medicaid, Private Insurance
Recipe
Bodies, Plan Identification, Victims, Perpetrators
Schemes
Recipe Recipe
Schemes Schemes
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Illicit Patients
Illicit Providers visits
bills
Group Health Insurance (multiple programs)
Sells
“Fills”
prescribes
recruits
bills
takes
Rx
Rx
Rx
Rx
fills
Illicit Pharmacies
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Illicit Providers
Auto Coverage Insurance
recruit
Provide treatments
Pharmacy Criminals- New Auto Schemes
Broker provides insurance
Fake an Accident
bill
Visits, DME, Diagnostics
Illicit Patients
I don’t have auto insurance!
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HCC Overview
Primary Health Care Continuum (“P-HCC”):
Clinical, Service, Product, and Financial Integration
Third Party Vendors: Case Managers; legal system; durable medical equipment; drug
manufacture; pharmaceuticals; transportation; labs; billing agents; suppliers; etc.
Third Party Vendors: Case Managers; legal system; durable medical equipment; drug
manufacture; pharmaceuticals; transportation; labs; billing agents; suppliers; etc.
White Collar & Organized Crime: waste, fraud, and abuse.White Collar & Organized Crime: waste, fraud, and abuse.
Employer Plan Sponsor
Office of Personnel
Management Sponsor
Patients:Insured
Employee
Publicly insured
Privately insured
Gov. Employee
Uninsured w $
Uninsured w/o $
Vendors:undisclosed & disclosed
parties
Plan Sponsors: Payer’s: Private &
PublicPayer’s: Private &
Public
Provider’s:Hospitals
Professional StaffOutpatient Care
Office based careHome based care
Provider’s:Hospitals
Professional StaffOutpatient Care
Office based careHome based care
Segmented, Fragmented, Insulated, Lacks Service & Price Transparency
Government Plan Sponsor:
Medicare; Medicaid
Private Insurance Plans
E-Health Data Driven Decisions
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Audit Check List • Health Care Continuums
– Primary Healthcare Continuum – Secondary Healthcare Continuum – Information Continuum – Consequence Continuum – Transparency Continuum – Rules Based Continuum
• Information Pipelines
– HIP = identification of health information – ARP = identification of the monetary aspects of the health information – OFA = identification of the procedural aspects of the health information and
the monetary transactions – PMA = identification of products involved in the delivery of healthcare services – SMA = identification of the services involved in the delivery of healthcare
services – CMA = identification of the consumer selection or choice activity in the
delivery of healthcare services
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You Pick
• Left or Right?
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You Pick
• Left or Right?
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You Pick
• Left or Right?
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You Pick
• Left or Right?
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You Pick
• Left or Right?
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Quality Control?
• This an old cement mixer used to give counterfeit Viagra tablets their blue coloring.
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You Pick
• Left or Right?
AmgenDrugmaker2,000 U/ml
Cardinal8,931 boxes2,000 U/ml
AmerisourceBergen3,363 boxes2,000 U/ml
J& M PharmacareFL Pharmacy
Bought 12,294 boxes2,000 U/ml
Armando RodriguezFL Go-Between12,294 boxes
2,000 U/ml
Jose GrilloAlleged FL Counterfeiter
2,000 U/ml → 40,000 U/ml
Silvino MoralesRelabeled Vials
Printer in HialeahMade Counterfeit
Labels
Playpen SouthFL Strip Club
Nick Just/Paul Perito
Double JUnlicensed FL
Wholesaler
Costal MedicalVA Wholesaler
135 BoxesLot 2970
Tradewinds TradingTX Wholesaler
135 boxesLot 2970
Rebel DistCA
Wholesaler
GrapevineTrading
OH Wholesaler
AD PharmaceuticalFL Wholesaler
2 boxesLot 2970
Medix IntlCarlos Luis
TX Shell Co.180 Boxes Lot 2970
Y W ConsultantsUnlicensed FL
Wholesaler
Ivan VillarchaoFL
45 BoxesLot 2970
Armin MedicalNH Wholesaler
129 BoxesLot 2970
Express RXEddie Mor
TX Shell Co.180 Boxes Lot 2970
Premier Medical GroupGA Shell Co.
460 Boxes Lot 1091812 Boxes Lot 2970
Optia MedicalMark NovoselUT Shell Co.
45 BoxesLot 2970
Jemco MedicalFL Wholesaler
16 BoxesLot 2970
AmeRxSusan CavalieriFL Wholesaler
182 BoxesLot 2970
CSGTN Wholesaler
460 BoxesLot 1091
CSGTN Wholesaler
812 BoxesLot 2970
Dialysist WestAZ Wholesaler
1056 Boxes, Lot 2970
Dialysist WestAZ Wholesaler
461 Boxes, Lot 1091
AmerisourceBergen KY Distribution Center1517 Boxes
CVS, NY
Timothy Fagen
--- probable sales∙∙∙ unknown sources and sales→ confirmed sales
Patient Pharmacy
National Wholesaler
Regional Wholesaler
Gray Market
National Wholesaler
Manufacturer
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• Rent-a-Patient Scheme – In this scheme organizations pay for—or “rent”—
individuals to go to clinics for unnecessary diagnostic tests and cursory examinations. The scary thing is that licensed physicians sometimes participate in the rent-a-patient scheme.
– Case and point: Robert Bourseau, 75, was sentenced to 37 months in prison and ordered to pay $4.1 million in restitution for his role in a scheme to defraud Medicare and Medi-Cal. He pleaded guilty in June to paying a recruiter to deliver homeless patients to his hospital for unnecessary medical services.
Types of Schemes
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• Pill Mill Scheme – In this scheme, separate health care individuals and
entities (usually including a pharmacy) collude to generate a flood of fraudulent claims that Medicaid pays. After a prescription is filled, the beneficiary sells the medication to pill buyers on the street who then sell the drugs back to the pharmacy.
– Example: Rick Kloxin, pharmacist in charge of Hogan’s Pharmacy in Lyons, Kans., was found guilty in an internet pill mill scheme. Kloxin pled no contest and was found guilty of 14 misdemeanor counts of violating Kansas Pharmacy laws.
Types of Schemes
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• Drop Box Scheme – This scheme uses a private mailbox facility as the
fraudulent health care entity’s address, with the entity’s “suite” number actually being its mailbox number. The fraudulent health care entity then uses the address to submit fraudulent Medicare, Medicaid, and other insurance claims and to receive insurance checks.
Types of Schemes
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• Third-Party Billing Scheme – The third-party billing scheme revolves around a third-
party biller—who may or may not be part of the scheme—who prepares and remits claims to Medicare or Medicaid (electronically or by paper) for health care providers. It is possible, however, for a third-party biller to defraud Medicare, Medicaid, and others by adding claims without the providers’ knowledge and keeping the remittances or by allowing fraudulent claims to be billed to Medicare or Medicaid through its service.
– Example: Recently, in Miami, Ihosvany Marquez and several alleged conspirators were indicted on charges of having filed $55 million in phony Medicare claims for HIV, AIDS, cancer, pain and varicose vein treatments.
Types of Schemes
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Detection: Data Mining • Claims Data
– Address profiling of patient – Address profiling of provider – Cross reference of Facility Professional, DME, and
Rx data bases – Beneficiary profiling
• Claims Data Sample membership_id PAT_ID last_name first_name subscriber_id long_subscriber_id address_1 address_2
15232 01 Doe John 123456789 123456789-001 540 PARKWAY 305215233 01 Doe John 123456789 123456789-001 540 PARKWAY 305215234 02 Bella Jane 123456789 123456789-001 800 PARKWAY 305215235 03 Bella Jane 123456789 123456789-001 800 PARKWAY 305215236 04 Austin Steve 123456789 123456789-001 600 PARKWAY 3052
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Detection: Data Mining
• Claims Data Sample – Jane Bella Drug Purchases: 4 Different Pharmacies –
70% with One Pharmacy – 12 month activity • 90 OXYCONTIN • 120 DIAZEPAM • 60 CYCLOBENZAPR • 30 METHADONE • 90 OXYCODONE • 90 OXYCONTIN • 120 DIAZEPAM • 60 CYCLOBENZAPR
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Detection: Data Mining
• Claims Data Sample – Jane Bella Drug Purchases: 4 Different Pharmacies –
70% with One Pharmacy – 12 month activity continued
• 30 METHADONE • 120 OXYCODONE • 120 OXYCODONE • 30 METHADONE • 60 CYCLOBENZAPR • 120 DIAZEPAM • 90 OXYCONTIN • 90 OXYCONTIN
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Detection: Data Mining
• Claims Data Sample – Jane Bella Drug Purchases: 4 Different Pharmacies –
70% with One Pharmacy – 12 month activity continued
• 120 DIAZEPAM • 60 CYCLOBENZAPR • 30 METHADONE • 90 OXYCODONE • 14 METRONIDAZOL • 20 HYDROCO/APAP • 12 METHERGINE • 21 METHYLPRED5AZITHROMYCIN • 120 DIAZEPAM
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Operational Flow Activity (OFA)Operational Flow Activity (OFA)
(ILLICIT Market Activity)(ILLICIT Market Activity) Pharmaceuticals Table 4.aI
Pharmaceuticals Table 4.aI
Drug Research
FDA Approvals
Drug Manufacture- foreign vs domestic
Drug (re) Distribution primary wholesale
Drug (re) Distribution – retail domestic & foreign: Physicians…Pharmacies…Facility Based Care
(licensed facility, pharmacists, physicians)
Research, Regulatory/Gov Requirements, Compliance, Distribution,Packaging, Wholesale, Retail: Requirements & Standards
Drug (re) Distribution secondary wholesale
(re) Packaging
(re) Packaging
340B Abuse; Benefit Plan Manipulations; false claims; vendor, employee, corporate
fraud; organized crime; kickbacks
Manipulations of product & pricing; illicit distributions;
introduction of altered products,
counterfeit
Medically unnecessary distribution
False Research;
noncompliance
Marketing & Sales Miss representations throughout
Waste, fraud, abuse
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Follow the Money: What is the offense?
What type of Patient?
Insured
Employee
Gov. Employee
Uninsured w $
Uninsured w/o $
Who is funding the plan?
Gov. Plan
Premium based Payer
Self funded employer
Data & Documents Observations & Interviews Analytics: $ & Operational SOAP: Patient Information
Source Predication Fraud Theory Investigation & Report
What type of Providers?
Hospital
OPS
MD Office
Nursing Home
Other
What type of Payer?
TPATPA/Premium
Other Parties?
Who What Why Where When
Anomaly Data Analysis ProfilerFRAUD PROFILER 27 Medical Business Associates, Inc. © 2013
Sample Documents
• Dates • Content • Intent
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• Issues: – Dictated one month after
procedure. – “specimens taken” – Narrative reference to
procedure the next day, “Will Check colonoscopy in the morning” but dictated 3/8/06 – no addendum noted.
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• Issues: – Format indicates a
different transcription system and source.
– Dictated, transcribed the same date of procedure
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The Story
• Doctor has a habit of submitting unbundled procedure codes
• Included: Procedures that were never performed
• Doctor is pursued in a medical malpractice case
• The irony – if he would have performed the services billed, the patient would have had a different outcome
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Electronic Issues
• Electronic system did not document or track addendums
• The billing codes were not documented in the medical record
• The doctor documents “specimens taken” but no pathology bills exist nor charges for the processing or collection of the specimen
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Sample: Sequencing & Content Issues
Issues:
• Dictated 5/23/05 T 5/23/05
• Electronic MD Signature 5/27/05
• Dictated clinical content conflicts with hand written narratives
• Continuation sequence 112421
• Dictator #15432
• Original sequence unclear (3 pages)
• Outsourced Transcription company
• Identifies transcriber
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Sample: Sequencing & Content Issues
Issues:
• Dictated on 5/17/2005 T 5/23/08
• No MD Electronic Signature Date
• Continuation sequence 113518 (3 pages)
• Not clear what content was changed
• Does not identify transcriber nor dictator
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Sample: Sequencing & Content Issues
Issues:
• Dictated on 5/17/2005 T 5/20/05
• MD Electronic Signature 8/8/05
• Continuation sequence 155019 (4 pages)
• Dictator #15482
• Not clear what content was changed
• Transcriber Identified as outside company
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Sample: Sequencing & Content Issues
Issues:
• Dictated on 5/17/2005 T 5/23/05
• MD Signature Date 8/8/05
• Continuation sequence 113525 (1 pages)
• Dictator #15482
• Transcriber Identified as outside company
• Corrected date 8/1/05
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Sample: Copy & Paste
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Sample: Copy & Paste 10/8/2003
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Sample: Copy & Paste
Issues: Too easy to replicate data and findings Have found wrong data associated with incorrect patient Increase tendency towards medical errors
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Questions?
Rebecca S. Busch RN, MBA, CCM, CFE, CPC, CHS-III, CRMA, CICA, FIALCP, FHFMA
580 Oakmont Lane • Westmont, IL • 60559 (PH) 630.789.9000 • (FAX) 630.908.3349 • www.mbaaudit.com
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