Medical Mutual of Ohio catches $6.2 million in fraudulent claims
Posted by Sarah Jane Tribble/Plain Dealer Reporter January 07, 2009 18:20PM
Categories: Business Impact, Impact, Insurance, Real Time News, Sarah Jane Tribble
Updated at 6:20 p.m.

Medical Mutual of Ohio, the state's largest health insurer, said it caught a record $6.2 million in fraudulent health-care claims last year, up from nearly $5 million the year before.

The company credits its computer software and a diligent investigative unit, which includes ex-police officers, for the increase.

The privately owned Cleveland-based company, which has 2,700 employees and serves about 1.6 million customers, is one of a growing number of insurers fighting fraud in the hopes of controlling health-care costs in a weak economy.

Health-care fraud typically occurs when doctors and other providers inaccurately bill the insurer or write unneeded prescriptions and perform unneeded procedures, said Lou Saccoccio, executive director of the National Health Care Anti-Fraud Association.

"It drives up cost -- absolutely it does," Saccoccio said. "Three to 5 percent of what insurers pay out in health benefits is fraudulent and that's going to be reflected in the premiums."

Medical Mutual's news of recovered dollars comes during a difficult time for health insurers. Two of the nation's largest health insurers plan job cuts in the wake of investment losses and a weak economy in which employers and consumers are reducing health care coverage. Cigna said earlier this week that it would cut 1,100 jobs, or 4 percent of its work force, by mid-2009; Aetna said last month that it would cut 1,000 jobs, or 3 percent of its work force.

Medical Mutual, the oldest health insurer in Ohio and one of Cleveland's largest employers, has no plans for layoffs -- though it is always "cautious on hiring," said Jared Chaney, Medical Mutual's chief communications officer.

Unlike some publicly traded competitors, the company does not answer to Wall Street, Chaney said.

"We don't have the pressure to meet quarterly targets set by analysts and year-over-year growth goals," Chaney said. "We want to turn a small profit because that profit goes into a surplus."

Medical Mutual has an operating surplus of nearly $1 billion, he said.

It's not all about money for John Shoemaker, manager of the 11-person financial investigations unit at Medical Mutual. "Not only do they steal," Shoemaker said. "In a lot of cases the services that they [doctors] render become questionable and I wonder if they're not hurting patients."


Tags: health care fraud, health costs, Medical Mutual of Ohio, National Health Care Anti-Fraud Association
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Wachovia recommended that CHS take part in a securities-lending program. 2003

CHS determined that the securities-lending program was proving too risky,

Wachovia Corp Sued by Carolinas Health Care System for More than $19 Million in “Bad” Investments

Posted On: January 19, 2009 by Shepherd Smith & Edwards
Wachovia Corp Sued by Carolinas Health Care System for More than $19 Million in “Bad” InvestmentsCarolinas Healthcare System (CHS) is suing Wachovia Corp for alleged bad investments that resulted in losses valued at over $19 million. CHS is also accusing the bank of “directly misleading” it, misrepresenting the risks associated with the investments, and failing to follow the hospital system's orders that it be withdrawn from the securities-lending program. Wachovia spokesperson Mary Eshet says that the company disagrees about the allegations, was always in compliance, and only made appropriate investments for CHS.

In 2003, according to the investment fraud lawsuit, Wachovia recommended that CHS take part in a securities-lending program. As a participant, a third party would borrow securities from CHS's portfolio in return for collateral that would be invested by Wachovia until the securities were returned. This would also hopefully result in additional returns.

Per the agreement, Wachovia was only supposed to invest in safe, liquid, quality securities. Any time CHS opted to withdraw from the program, the hospital system was supposed to get all of its investments back within five business days. Also, Wachovia would be allowed to keep 40% of the profits on one account and 35% on the other account.

Last summer, CHS determined that the securities-lending program was proving too risky, especially with the markets collapsing. In September, CHS notified Wachovia to return all borrowed securities right away.

Wachovia couldn’t return all of the securities immediately. Wachovia had invested for CHS $14.9 million in Sigma Finance Corp-issued floating rate notes (now worth $750,000) and $5 million in Pricoa Global Funding floating-rate notes (now worth $4.95 million).

The lawsuit contends that Wachovia never notified Carolinas HealthCare System that the investments were not appropriate until CHS decided to end its participation in the securities-leading program. 5 days after Sigma went into receivership last October, Wachovia told the hospital system for the first time that its investment was, at that time, worth just $1.8 million. CHS says there is no market for the Pricoa notes.

CHS contends that Wachovia gained 40% of the profits but did not suffer any of the losses. The hospital system is solely responsible for returning the lost collateral to its securities borrowers.

CHS sues Wachovia over investment advice, Charlotte Observer, January 15, 2009

CHS files suit vs. Wachovia over losses on investments, Charlotte Business Journal, January 9, 2009


Related Web Resources:
Carolinas HealthCare System

Wachovia Corp

Call or e-mail Shepherd Smith Edwards and Kantas LLP today.

United Health Group, Cuomo goes after United Health

Cuomo goes after United Health
Updated: 01/13/2009 09:26 PM
By: Erin Billups

NEW YORK STATE -- "I'm putting all the other healthcare insurance companies on notice today. This is the first step today with United," said Attorney General Andrew Cuomo.

After an investigation into allegations of unfair insurance reimbursement rates, United Health Group, one of the country's largest health insurers, has agreed to shut down its subsidiary, Ingenix, the nation's largest provider of health care billing information. Cuomo says Ingenix intentionally skewed the rates used when patients saw a doctor out of their coverage network.

"The system basically forced consumers to write a blank check to the doctor. They had no other guidance," Cuomo said.

Many large and small insurance providers use Ingenix, giving the company customer's billing information and all receiving the same reimbursement rate.

"Everyone bought into the system, everyone agreed, everyone has the same numbers. It was very difficult to detect," Cuomo said.

So customers would go to out-of-network doctors thinking they'd get, say, 80 percent back of what they were billed, only to find out that Ingenix would give back 10 to 28 percent less, calling that, the quote, usual and customary cost.

Mary Jerome, is being treated for advanced stage ovarian cancer. After she discovered her reimbursements were too low, she reported it to Cuomo's office.

"I felt like I had to battle twice, I had to battle cancer and I then felt I had to battle my insurance company,” said Jones. “It was almost too much to bear."

Now fewer people will have to bear that burden. United has also agreed to pay $50 million to a qualified nonprofit organization that will create a new independent database and reimbursement system. It will also develop a website where customers can find out, in advance, how much they'll pay before they go to the doctors.

But the investigation continues. Cuomo says one by one, they'll be investigating other insurance companies.

"I believe all these companies that have been involved with Ingenix, that there's a very strong case that they were perpetrating consumer frauds. And we are going to aggressively pursue those cases," Cuomo said.

In a press release, United Health's president said they're confident "the agreement will enhance the transparency of information" for consumers. But it seems this was just the tip of the iceberg.

'...Six strategies for waste elimination: ...'

Eliminating Waste in Health Care


The ability to eliminate unnecessary cost is absolutely critical to health care industry. Total spending was $2.3 TRILLION in 2007, or $7600 per person [1]. Total health care spending represented 16 percent of the gross domestic product (GDP). U.S. health care spending is expected to increase at approximately 7% levels for the next decade reaching $4.2 TRILLION in 2016, or 20 percent of GDP [1].

In 2007, employer health insurance premiums increased by 6.1 percent - two times the rate of inflation [2]. The annual premium for an employer health plan covering a family of four averaged nearly $12,100. The annual premium for single coverage averaged over $4,400 [2]. Experts agree that US health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.

So, how health care system can eliminate waste? The results from my research about medication delivery systems conducted over two years at one community hospital provide some answers to this question.

The results are:
• Fifty two out of sixty three nurses (82.53%) highlighted poor training for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
• Fifty five out of sixty three nurses (87.3%) reported confusion about their role expectation with respect to medication error reporting and prevention. All technicians stated similar concerns.
• Fifty four out of sixty three nurses (85.7%) specified lack of feedback as important factor affecting their psychological safety towards error reporting and prevention efforts. Four out of 6 technicians (66.67%) pointed to the same issue.
• All nurses and all technicians (100%) highlighted productivity pressures as the most stress-generating factor on their daily work averting them from medication error reporting and prevention.
• Forty four out of sixty three nurses (69.8%) and three technicians (50%) suggested group behavior influence as another major factor behind poor medication error reporting and prevention.
• Forty eight out of sixty three nurses (76.19%) indicated difficulties with utilizing the mechanisms for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.

Therefore, based on the ‘voice’ from the front line staff, I propose the following six strategies for waste elimination:
1) First, healthcare organizations should recognize the growing need to advance the understanding about healthcare delivery systems, unnecessary waste, as well as Quality Improvement (QI) programs by health care professionals. This can be done via continuum education training on systems and QI.

2) Second, health care organizations should start recognizing their frontline professionals as assets rather than costs. It is everybody’s job to eliminate waste and to do improvements. Therefore, the role expectation with respect to waste elimination and quality improvement should be well communicated to all frontline employees and continuously supported by managers and administrators.

3) Third, organization-wide and constructive feedback to frontline health care professionals about QI needs to be provided on a continuous basis. My research found that health care professionals who felt neglected and under-informed regarding the changes often responded with low motivation and discouragement towards QI efforts.
4) Fourth, the productivity pressures, often mentioned by frontline workers as one of the major contributing factors causing the low QI efforts, should be offset by redesigning systems that minimize the unnecessary waste during daily work. This should allow health care professional to devote more time to continuous improvement efforts.

5) Fifth, to remove the undesired group behavior, managers should physically spend more time and effort to establish and support a culture of excellence with high commitment to patient safety, waste elimination and QI.

6) Finally, all unit managers should provide active leadership at the unit floor for promoting standardized behavior with respect to procedural compliance. The goal is to eliminate the variability in the process by creating a culture that values procedural compliance. In additions, promoting procedural compliance by the manager at the unit floor can increase the rate of error recognition and QI efforts via root-cause problem solving, enhance the manager’s reputation for patient safety, and increase the confidence of health care professionals in her/his leadership abilities/skills.

I hope that the proposed implications and discussions will help health care organizations to achieve satisfactory improvement in waste elimination efforts. In addition, I believe that the proposed insights into this area have potential to enhance professional development of health care managers and professionals.

1. Poisal, J.A., et al, Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact. Health Affairs (21 February 2007): W242-253.
2. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2007 Annual Survey. 11 September 2006. http://www.kff.org/insurance/7672/index.cfm

Federal agents raid convalescent home headquarters

Federal agents raid convalescent home headquarters
By TONY SAAVEDRA and RONALD CAMPBELL
The Orange County Register
Wednesday, December 17, 2008

Federal agents on Wednesday raided the Mission Viejo headquarters of a national chain of convalescent homes in what company officials said appears to be an investigation into suspected Medicare fraud.

Officials from Ensign Group Inc. said the Department of Justice has been investigating the company since 2006. Greg Stapley, corporate vice president and legal counsel, said the firm may have inherited the problem from its strategy of acquiring troubled group homes.

"We take in a lot of facilities that are in trouble and turn them around," Stapley said.

The U.S. Attorney's Office in Los Angeles could not be reached for comment.

Founded in 1999, The Ensign Group owns and leases 61 convalescent centers in six states, including three in Orange County: Palm Terrace Health Care Center in Laguna Woods; Sea Cliff Health Care Center in Huntington Beach; and Victoria Health Care Center in Costa Mesa. Ensign has a total of 7,400 beds and raised $411 million in revenue in 2007.

According to documents filed by the company with the Security Exchange Commission, the Department of Justice has been looking into the billing and reimbursement practice of some of the firm's subsidiaries.

In 2007, federal attorneys in Los Angeles subpoenaed the firm's bank documents, but later rescinded the demand. The subpoena asked for financial transactions involving Ensign, 10 subsidiaries, an outside investor group and some company officers, said the SEC report.

Later that year, the U.S. Attorney's office sought a meeting with an Ensign employee regarding an investigation into Medicare claims with the federal Department of Health and Human Services Office. The request for a meeting was rescinded, according to the SEC report.

In December 2007, the firm's accounting contractor was subpoenaed and, later, another employee was contacted.

"We believe that the U.S. Attorney may be conducting parallel criminal, civil and administrative investigations involving the Ensign Group and one or more of our skilled nursing facilities," the company said in SEC documents.

The raid on Wednesday was the first formal confirmation of the federal probe.

In November 2006, the company conducted its own internal investigation into Medicare reimbursements and found that documentation was missing for $224,000 in Medicare claims, documents said. These claims have been reported to the federal government, according to SEC statements.


Contact the writer: tsaavedra@ocregister.com or 714-796-6930

Legal Advocacy
Supreme Court Refuses to Allow Federal Labeling Law to Shield Against Fraud/Misrepresentation Claims


The U.S. Supreme Court ruled that manufacturers of potentially dangerous products are not shielded from state consumer law merely because their products have complied with federal labeling laws. The specific product at issue in Altria Group Inc. v. Good was “light” cigarettes, but the Court is also considering this term a case that asks whether federal law preempts state product liability claims against pharmaceutical manufacturers for labeling that fails to adequately warn of a drug’s risks.

AARP filed “friend of the court” briefs in both the cigarette and the pharmaceutical case, urging the Court not to preempt state laws because doing so would limit state efforts to protect the health and welfare of their citizens -- allowing consumers who have been injured as a result of a manufacturer’s deceptive practices or faulty manufacturing without a remedy for the harm.

The dispute


Stephanie Good was a smoker who lived in Maine and favored Marlboro Lights and Cambridge Lights cigarettes, believing the marketing claims by cigarette manufacturers that “light” cigarettes were a healthier alternative to regular cigarettes. After learning that the marketing claims were false, she sued Altria and other cigarette manufacturers. She alleged that they had falsely marketed their “light” cigarettes as containing lower tar and nicotine in order to convey to consumers the impression that the cigarettes are less harmful than regular cigarettes. The class action lawsuit argued that in contrast, light cigarettes can actually be more harmful than regular cigarettes due to the cigarettes’ design. The lawsuit alleged that the companies had known this information and had deliberately deceived consumers systematically and over many years.

Plaintiffs specifically invoked the protections of the Maine Unfair Trade Practices Act (MUTPA), which prohibits unfair or deceptive acts or practices in commerce. The defendant cigarette companies argued that their cigarettes complied with federal cigarette safety warning laws and that the federal labeling law preempted the state consumer protection law.

Numerous similar lawsuits have been filed around the country and, faced with conflicting rulings from various courts, the U.S. Supreme Court agreed to take up the matter and resolve this preemption issue.

The ruling


The Supreme Court began with the assumption that the historic powers of states to regulate the health and welfare of their citizenry was not to be disturbed unless Congress specifically intended to do so. It then looked to the enactment of the federal Labeling Act of 1965 (which required cigarette manufacturers to include specific warnings about the potential hazards of smoking cigarettes) to determine whether Congress intended to preempt state labeling laws. Reviewing the many amendments and refinements enacted into law, the Court did find the intent to prohibit states from enacting stronger cigarette labeling laws – but only those laws that specifically addressed the labeling of cigarettes.

The Court was unable to find any support for the argument that state fraud laws were to be preempted. In fact, the court noted in a prior cigarette labeling case, unlike the concerns about wide divergence in labeling that led to Congress limiting state ability to mandate cigarette labels, fraud claims “rely only on a single, uniform standard: falsity.” Or, as AARP’s brief put it, “Make no mistake, this case is about fraud.” Since the MUTPA only addressed fraud and deceit as a general business practice, its general principles were not to be disturbed and defendants were not shielded by the federal cigarette labeling law.

In other words, the Court ruled that federal cigarette labeling law does not protect a manufacturer from liability for breaching the general duty not to lie to the public.

The ruling carries additional significance because the Court is considering this term another case that tests the balance between federal and state law. In Wyeth v. Levine, the pharmaceutical manufacturer is seeking to be shielded from liability because it complied with federal Food and Drug Administration approvals that did not require it to warn of specific dangers. In that case, Diana Levine went to the hospital suffering from migraines but had to later have her arm amputated after doctors intravenously administered a drug that destroyed her arteries. Levine alleged that the drug manufacturer had evidence that if the drug reached arteries, it could cause gangrene but despite this it did not warn of this danger. A jury agreed that the company had failed to warn of risks and awarded her $6.7 million in damages.

At trial and in its appeal, Wyeth argued that it was exempted from state tort law because the federal Food and Drug Administration (FDA) had approved the drug without requiring the warning sought and this preempted state tort law.

AARP’s briefs


In both Altria and Wyeth, the AARP “friend of the court” briefs filed by AARP Foundation Litigation attorneys pointed out that while regulatory agencies impose Congressionally-authorized requirements on manufacturers, those agencies face particular challenges. Both the Federal Trade Commission (which oversees cigarette labeling) and the Food and Drug Administration (pharmaceuticals) are chronically underfunded, often criticized for reliant relationships with industry, and have limited authority over the products -- with very little FTC oversight over cigarettes and extremely limited post-market oversight by the FDA.

Fortunately, there has been another safety net built into the legal system – the traditional tort lawsuit. By imposing the possibility of significant monetary penalties directly on wrongdoers, tort lawsuits incentivize those who develop, make, and distribute potentially dangerous products to do so with the utmost consideration for human health. The tort system plays a critical complementary role with agency regulatory processes to help ensure that items placed into the marketplace are as safe as possible and that any necessary warnings are adequately written and targeted.

The brief in Altria detailed the history of misrepresentation and deception in the marketing of “light” cigarettes, noting the voluminous evidence that has been presented indicating cigarette companies’ knowledge both that smokers were sensitive to health claims and that the health claims were exaggerated. One example of the sensitivity of “light” cigarette consumers: following aggressive health-based campaigns, the market share for “light” cigarettes skyrocketed from 2% in 1967 to 81% of cigarette sales in 1998.

Finally, AARP’s brief pointed out the absurdity of allowing the federal law to preempt state fraud law. Under a theory advanced by one of the defendants, the brief noted, cigarette manufacturers would be shielded from liability even if they made the following claims ”Smoking fights Parkinson’s Disease,” or “Smoking wards off depression.” As the brief put it, “Under Philip Morris’ reading, the Labeling Act – a statute designed to ensure that the public is informed of the risks of smoking – becomes an instrument of deception.”

AARP filed its brief in Altria with other health care and consumer protection advocates. The narrow 5-4 decision is a welcome ruling and could pave the way for further bolstering of state law remedies when the Court turns to Wyeth later this Term.

Contact persons:

Julie Nepveu
jnepveu@aarp.org

Stacy Canan
SCanan@aarp.org

Department of Health and Human Services had failed to guard some of their confidential information.

HHS Mistakenly Leaks Medicare Recipients' Private Information
By Elaine Grant on Wednesday, December 17, 2008.


This week, thousands of Medicare recipients got an unpleasant surprise when they learned that the Department of Health and Human Services had failed to guard some of their confidential information.
NHPR's Elaine Grant has the story.

Web resources:

New Hampshire Department of Health and Human Services
New Hampshire ServiceLink

New Hampshire Department of Justice
Consumer Affairs Identity Theft Toolkit

It’s open enrollment time for people who use Medicare drug prescription plans, or the so-called Medicare Part D.

Figuring out which drug plan is the best one -- can be confusing enough.
But now there’s an added problem for 93-hundred New Hampshire residents.
The state Department of Health and Human Services says a staffer mistakenly sent their private information to health care providers.

HHS Associate Commissioner Nancy Rollins says the employee sent a routine email about Part D prescription plans to 61 long-term care and home health organizations in the state.

Staffers at those companies use the information to help their clients choose the right Medicare prescription plans.
But, says Nancy Rollins, something went wrong.

Rollinsfacts.wav: Unfortunately the information was contained in an Excel spreadsheet, and it was attached to a workbook. The workbook had a tab and a document that contained information about the 9,300 individuals.

That information included names, addresses, social security numbers and the amount of people’s monthly Medicare Part D premiums.
Rollins stresses that it did not include medical or prescription information.
The department discovered the error on December fourth when a health care provider called them.
HHS immediately called the attorney general’s office, reported the incident and set about trying to remedy the problem.

Rollins1.wav: We contacted the 61 professional health care providers, that included independent case managers home health care providers and so forth and asked them to delete the information and to provide us confirmation that that had been done.

New Hampshire organizations that have had a data breach are required by law to notify the people involved.

On Monday, HHS sent thousands of letters informing people about the incident.
Those letters advise people on ways to avoid becoming a victim of identity theft.
Among those prescriptions: put a fraud alert or a credit freeze on your accounts.
A fraud alert is exactly what it sounds like – it alerts your credit card company to be on the lookout for strange or unlikely charges.
A credit freeze keeps people from checking your credit report, a necessary step when opening accounts or making loans.

It’s a more draconian measure – although it can deter criminals, it can also make it harder for people to open legitimate accounts or to borrow money.
Lauren Noether is a senior assistant attorney general in New Hampshire.

Noetherfreeze: If you know you’re not going to be borrowing any money, you put a freeze on it and that way if someone has your name and social security they’re not opening bank accounts in your name or taking out a mortgage in your name that you may later on be presumed to be liable for.

The Department of Health and Human Services has set up hotlines for concerned citizens.

By early afternoon on Wednesday, almost 300 people had called.
HHS Associate Commissioner Nancy Rollins says the department is still investigating the incident and determining what, if any, disciplinary actions it will take against the employee.She admits that the department did not have policies in place that could have prevented the problem.

Policy.wav: We are addressing the individual issue here, but also looking at if there are policy and protocol ramifications that we need to revisit.

Rollins says participants who did not receive a letter from the department, did not have their name and information leaked.
She adds that if you need help with fraud alerts or credit freezes, you can get assistance from one of 13 Service Link organizations around the state.
Service Links are agencies that counsel seniors and adults with disabilities about long term care.

For help, call the Department of Health and Human Services.
For NHPR News, I’m Elaine Grant

Anti-fraud efforts snagged $1.1 billion in ’07...is this something to be proud of?

Anti-fraud efforts snagged $1.1 billion in ’07

Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.
Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.

Not sure if this is something to boast about!>?

What about the NCFE case in Ohio? National Century Finance Enterprises, Inc., the largest private fraud case in the history of this country!


In fiscal 2007. the agencies appropriated $166 million from the Medicare trust fund and recovered $1.1 billion

In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion


Posted: December 3, 2008 - 3:00 pm EDT

Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.The program, established by the Health Insurance Portability and Accountability Act of 1996, calls for the agencies to appropriate money from the Medicare trust fund to fight fraud perpetrated against federal health programs. Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.

The dollars returned to the federal treasury as a result included $201 million in criminal fines, $211 million in penalties and damages, and $186 million from disallowed payments identified and recovered through audits. In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion. Money collected on behalf of state Medicaid programs and private payers is not represented in the figures. (See the reports for 2007 and 2006.) -- by Gregg Blesch


http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20081203/REG/312039974/1024/rss01&rssfeed=rss01&nocache=1&nocache=1

If only there were also programs like this in developed countries.

Monday, December 01, 2008
Two Important Resources Last month, I was fortunate to be able to attend the 13th International Anti-Corruption Conference in Athens, Greece, where I learned about two important additions to our resources relevant to the issues discussed on Health Care Renewal, specifically to improving integrity and transparency to the manufacture, promotion, and use of pharmaceuticals.

The Medicines Transparency AllianceFormed this year, this group seeks to bring "together at both the international and national levels, a diverse group of people with an interest in the pharmaceutical sector (stakeholders) to find ways to improve information flows, and increase transparency and accountability about the selection, regulation, procurement, sale, distribution and use of medicines in developing countries. By doing so, MeTA will improve how decisions are made about medicines, improve the way they are purchased and supplied, encourage innovative and responsible business practices, and increase the voice of patients and consumers." The Alliance will be focused mainly on developing countries, so that "when a country implements MeTA, it makes a commitment to progressively disclose a standard set of core data covering the quality, availability, price and promotion of medicines. This commitment also includes fully involving civil society, business and other stakeholders to work together to generate, disclose, debate and use these data to help address problems in the pharmaceutical market."

The Alliance has launched programs in Peru and Ghana, and plans to launch programs in Kyrgyzstan and Jordan.

The World Health Organization (WHO) Good Governance for Medicines Programme

This program has been in operation for several years, but seems to have a new and improved web-site. The site notes "Theft, extortion and abuse …the US$ 3 trillion-plus spent on health services worldwide each year are an obvious target for corruption. In fact, Transparency International estimates that 10 to 25 % of global public health procurement spending is siphoned off and stolen. Life-saving resources are being snatched away from the millions of people that need them most. The pharmaceutical sector, with its US$ 600 billion-plus global market value, is vulnerable to fraud." The goal of the programme "is to improve this situation. Guided by WHO’s Medicines Strategy 2004-2007 and launched in late 2004, the programme is raising awareness of abuse in the public pharmaceutical sector and promoting good governance. Its ultimate aim is to ensure that essential medicines reach people - not the black market."

If only there were also programs like this in developed countries.
Labels: Medicines Transparency Alliance, pharmaceuticals, WHO Good Governance for Medicines Programme


posted by Roy M. Poses MD at 11:42 AM

Links to this post

Condell, the largest health care provider in Lake County, Ill., $36 Million Settlement After Self-Reporting Possible Health-Care Fraud

Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care Fraud

December 1, 2008

Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care FraudCondell Health Network, parent corporation of Condell Medical Center, a 283-bed hospital in Libertyville - after voluntarily disclosing that it received improper Medicare and Medicaid payments - has agreed without litigation to pay the United States and the State of Illinois$36 million as a result of filing false claims for reimbursement, announced Patrick J. Fitzgerald, U.S. Attorney for the Northern District of Illinois. Condell, the largest health care provider in Lake County, Ill., made the voluntary disclosure earlier this year while in the process of being acquired by Advocate Health Care, of Oak Brook, Ill., which was scheduled to be completed today. Full release

Posted by Admin at 02:56 PM
http://www.newsunfiltered.com/archives/2008/12/condell_health.html

Here is one person's definition of Healthcare Fraud...a tip of the GLACIER!

Health Care Fraud Costs Billions
October 10th, 2008 · No Comments
By: LINDSEY O’NEILL, ESQ.

What is Health Care Fraud? Health care fraud occurs when health care professionals make false or misleading statements in order to benefit financially. Health care schemes are diverse and often complex.

Examples include overbilling, billing for services not even provided, double billing for the same procedure, billing for a more expensive procedure than actually performed, or billing separately for items that are less expensive when bundled together (for example a group lab tests). It is also fraudulent to receive a “kickback” for referring a patient to another doctor. Doctors have even been caught selling prescriptions to patients for cash.

Part of the reason health care fraud is so prevalent is because health care is so expensive and is such a massive system. It is not unusual for a carrier to cut a check for over $100,000 to someone it does not even know! Because it is so prevalent, billions of dollars are being drained from the Medicaid and Medicare Industries on fraudulent claims. Scam artists often close up shop and flee before investigators can even attempt to recover the fraudulently obtained funds.

However, the Justice Department has made health care fraud a top priority. Many investigations are the result of complaints from patients and the public at large. Because fraud is conducted for the most part “in secret” these tip-offs from health care consumers are extremely valuable to the FBI and other law enforcement officials. Criminal penalties for health care fraud can be very severe. If you are involved in a health care practice you believe may be considered fraudulent, contact an attorney for more information.

Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions

Well this is a start tocombat the fraud, howweverwhat about all the money that was stolen HCA over the years?

Just the money that HCA settled 'out of court' for was a FRACTION, a FRACTION of what they STOLE! And were still allowed to continue UNINTERRUPTED BUSINESS as USUAL!
mentored by Rixchard Rainwater and friends!

How about HCA paying ALL of the money,that was stolen mind you, back to the people, not just the fraction the government settled for, buit ALL OF the LOOT BACK!

Man charged with TennCare fraud
NASHVILLE — A Rutherford County man is charged with using the TennCare medical benefits of another individual in order to get health-care treatment he would otherwise have to pay for.

The Office of Inspector General (OIG) and the Rutherford County Sheriff’s Department today announced the arrest of Steven M. Barrett, 19, of Murfreesboro.


An indictment charges Barrett with one count of TennCare fraud and using someone’s TennCare card in order to obtain treatment at a health-care provider’s office in Rutherford County.

“Health-care benefits are not transferable to another person — even in the private sector — and it’s especially egregious for someone to steal the benefits of a person who legitimately qualifies for TennCare,” Inspector General Deborah Y. Faulkner said.

Illegally obtaining TennCare medical benefits is a Class E felony that carries a maximum penalty of two years in prison per charge. District Attorney William Whitesell Jr. will prosecute.

The OIG, a law enforcement agency separate from TennCare, began full operation in February 2005 and has worked cases leading to the arrest of more than 760 individuals for TennCare fraud, with nearly $1 million paid in restitution to TennCare, and total estimated cost avoidance in TennCare of over $122 million, according to latest figures.

Through the OIG Cash for Tips Program established by the Legislature, Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions. “Anyone can report suspected TennCare fraud by calling 1-800-433-3982 toll-free from anywhere in Tennessee, or log on to www.tncarefraud.tennessee.gov and follow the prompts that read “Report TennCare Fraud.”

$9.3 billion recovered between 1996 and 2005...are you kidding?

Trillions have been stolen and this DOJ should be satsified with $9.3 billion recovered...give me a break!


WASHINGTON, D.C.
Whistle-blowers play large role in uncovering healthcare fraud
Insiders helped authorities recover more than $9.3 billion between 1996 and 2005. For their efforts, they get 15% to 25% of the amount reimbursed.
September 2, 2008
Insiders aid in healthcare fraud cases

Whistle-blowers have helped authorities recover at least $9.3 billion from healthcare providers accused of defrauding states and the federal government since 1996, according to an analysis of Justice Department records.


The department intensified efforts in the 1990s to combat healthcare fraud by using private citizens with inside knowledge of wrongdoing. They now initiate more than 90% of the department's lawsuits focusing on healthcare fraud.

Whistle-blowers start cases by filing a sealed complaint in federal court. The department investigates and can intervene, assuming the lead role in the lawsuit.

Whistle-blowers then get 15% to 25% of the amount recovered.


Of the $9.3 billion recovered between 1996 and 2005, whistle-blowers got more than $1 billion, analysts estimated, writing for the Annals of Internal Medicine. The analysts' estimates are conservative.

$1.75 million as a result of fraudulent billings

July 17, 2008 in Health Fraud by Dave Westheimer

In Washington on Friday, US District Court Judge Colleen Kotar-Kotelly sentenced Martin McLaren of Bethesda, Maryland to 37 months in prison for making false statements in relation to health care matters. McLaren, an anesthesiologist who owned the Pain Management Center based in Hyattsville, admitted to receiving at least $1.75 million as a result of fraudulent billings submitted to Medicare, Medicaid and private carriers between 2000 and 2006 (Washington Times, DOJ).

Blog Published By
Wisenberg & Wisenberg PLLC: White Collar Criminal Defense Attorneys

Ten individuals associated with a Brooklyn-based medical clinic ...charges of conspiracy to commit health care and mail fraud.

NEW YORK—Ten individuals associated with a Brooklyn-based medical clinic — including the clinic’s owners and several of its medical practitioners – have been arrested on Three other individuals remain at large, although one was expected to surrender later Thursday.



Samuel Vilshanetski, aka “Dima,” Sviatoslav Jadan, aka “Slava,” and a third individual owned and operated a medical clinic located at 3003 Avenue K in Brooklyn, New York. The Avenue K Clinic was primarily engaged in the treatment of individuals who filed no-fault automobile insurance claims with insurance companies. Under New York State Law, no-fault insurance enables the driver and passengers of a vehicle registered and insured in New York to obtain benefits of up to $50,000 per person for injuries sustained in an automobile accident, regardless of fault.



Prosecutors say the Avenue K Clinic was a medical fraud mill which routinely billed automobile insurance companies under the no-fault program for medical “treatments” which were either never provided or unnecessary, because the person being “treated” did not medically need the treatments.



According to the complaints, the operators of the Avenue K Clinic paid thousands of dollars to “runners” who would recruit patients who were in car accidents — sometimes staged solely to commit insurance fraud — but who often suffered little or no injury from the accidents. These patients would undergo weeks or months of unnecessary “treatments” — such as physical therapy, chiropractory and acupuncture — at the Avenue K Clinic. The Avenue K Clinic then billed automobile insurance companies under the no-fault program for these unnecessary medical treatments, prosecutors said.



In the first two years of its operation, the Avenue K Medical Clinic billed insurance companies a total of approximately $3.6 million for no-fault medical services on behalf of more than 500 patients and, as of June 2008, had received approximately $1.2million from these insurance companies.



Vilshanetski, Jadan and the third individual owned and operated the Avenue K Clinic – making the initial financial investments and supervising the Clinic’s medial staff and operations. The owners of the Avenue K Clinic engaged so-called “runners,” including defendants Roman Satler, aka “Roma”, Shamil Tagiev, aka “Sammy”, Emmanuel Kelly, aka “Kevin”, Vladimir Deupont, aka “Vlad” and Feliks Khatsela, to recruit patients for the clinic for treatment.



According to the complaints, the owners paid the runners an average of approximately $2,000 per patient but paid them only after the referred patients had received enough treatments for the patient to be profitable. The recruited patients were required to attend the clinic for treatment regularly, sometime daily, and to agree to receive multiple MRIs. Even greater payments were offered to the runners when a patient was accepted as a client at one of several law offices associated with the clinic because the law offices paid fees to the clinic for each patient signed up as a client.



The owners relied on various means to obtain cash to pay the clinic runners. For example, the owners of the Avenue K Clinic laundered money through defendant Mark Pogoriler, aka “Lobster” by writing checks drawn on the accounts of clinic medical practitioners to Pogoriler’s medical transportation companies. In fact, Pogoriler provided no transportation services to the clinic and instead simply returned 90 percent of the value of the checks as cash.



The owners also obtained cash from kickbacks provided by outside medical suppliers and practitioners in exchange for the referral of business. Medical supply companies associated with Radion Aminov, the defendant, billed insurance companies for overpriced and often unnecessary medical supplies provided to Avenue K Clinic patients, and in return provided kickbacks to the Avenue K Clinic.



Gennady Broytman, aka “Genna,” the defendant, operated an MRI clinic that billed insurance companies for MRIs provided to Avenue K Clinic patients and paid kickbacks to the clinic owners. The Avenue K Clinic also hired doctors and medical

professionals to “treat” the patients recruited for the clinic by the runners, even though the majority of such patients did not need the medical treatments provided.



These medical professionals included defendants Romilla Anwar (a physician), Anatoliy Sunik (an acupuncturist) and Asnodin Dianalan, aka “Dino” (a physica ltherapist)(collectively the “medical staff.”) The medical staff provided unnecessary medical treatments and supplies to clinic patients, and also submitted bills to the insurance companies for more medical services than were in fact provided. 7-17-08

Since Poulsen's trial is now set to begin Oct. 1, it pushes the trial of James K. Happ, another former National Century executive....

Now why is this delay for Happ occurring? After the NOVEMBER election of course. Does any reporter really know where Happ is form or what his job at NCFE really was? If so, no one has yet to connect the dot!
Who does Happ really know? (Hint: Bush Connection)
The former CEO of National Century Financial Enterprises Inc. has successfully put off his trial on fraud-related charges by two months.

A federal judge ruled Friday that Lance Poulsen, the leader of the Dublin-based health-care financing company before it collapsed in 2002, will begin facing charges of securities fraud and conspiracy on Oct. 1 instead of Aug. 4. U.S. District Court Judge Algenon Marbley granted Poulsen's July 7 continuance request after Poulsen's attorneys argued they needed more time to review 40 boxes of documents the government is scheduled to make available between now and August.

"A two-month continuance will ensure that Poulsen has the time to obtain and review the documents that he plausibly claims are central to his theories of defense," Marbley wrote in his July 11 order.

Since Poulsen's trial is now set to begin Oct. 1, it pushes the trial of James K. Happ, another former National Century executive, to Dec. 1. Poulsen and Happ have both pleaded not guilty.

Poulsen, 65, co-founded National Century in 1991, building it into a major health-care financing company. It specialized in buying receivables from medical providers at a discount, which gave the health-care businesses the quick cash they needed. The receivables were then packaged as asset-backed bonds and sold to investors.

But National Century fell into Chapter 11 bankruptcy six years ago. The Justice Department alleged Poulsen and other executives ran a sophisticated Ponzi scheme that bilked investors out of nearly $2 billion. Poulsen pleaded not guilty to charges of conspiracy, securities fraud, wire fraud, money laundering conspiracy and concealment of money laundering.

Five other former National Century executives were found guilty in March of running a multiyear securities fraud at National Century. Poulsen was scheduled to go on trial with them, but his day in court on those charges was delayed because the government also accused him of trying to tamper with a witness.

Shortly after the March convictions of the five executives, Poulsen stood trial on the witness tampering charges. A jury found him and an associate, Karl Demmler, guilty of trying to bribe a government witness who is planning to testify against Poulsen in his securities fraud trial.

"...he will forfeit $850,000 in proceeds from the crimes....

Bowling Green Doctor Pleads Guilty To Health Care Fraud
Friday, 20 June 2008




A Bowling Green doctor has pled guilty to charges of health care fraud according to U.S. Attorney David L. Huber.


58 year old Verlon Lane Pierce has admitted to having defrauded health care benefit programs, including Medicaid by unlawfully billing those programs, for pharmaceutical drug samples provided to patients. He also admits he unlawfully purchased, sold and traded prescription drug samples. As part of a plea agreement, he will forfeit $850,000 in proceeds from the crimes.


Maximum potential penalties are 20 years in prison, a $500,000 fine and 3 years supervised release.

Verlon Pierce will be sentenced September 11 at 9 am in Bowling Green by Judge Thomas B. Russell.

Kendall Regional Medical Center and its sister HCA affiliates

Posted on Thursday, June 05, 2008



LAWFUEL - US Attorney News Releases - Three former employees of Kendall Regional Medical Center (“KRMC”), a full-service hospital located in Miami-Dade County, Florida, were charged in an Information filed today with conspiring to defraud the KRMC of nearly $7 million through a sophisticated purchase order scheme, announced R. Alexander Acosta, United States Attorney for the Southern District of Florida and Jonathan I. Solomon, Special Agent in Charge, Federal Bureau of Investigation, Miami Field Office. Specifically, the Information charges defendants Joanna Delfel, Victor Garcia, and Sylvia Oramas with conspiracy to commit wire fraud, in violation of Title 18, United States Code, Section 1349. If convicted, each defendant faces a maximum term of imprisonment of twenty years.

According to the Information, from 2001 through May 2007, the defendants, working with unindicted co-conspirators who held positions of authority at two medical supply companies, The Pharmed Group, Corp. (“Pharmed”) and Allied Medical Products, Inc. (“AMP”), participated in a fraud scheme in which the defendants entered unauthorized and false purchase orders and delivery verifications into the computerized system used by KRMC for all of its medical supply orders and purchases. These entries made it appear as if almost $7 million in medical supplies had been ordered and delivered to KRMC by Pharmed and AMP. Based on these false purchase orders, KRMC’s parent company, HCA, Inc. (“HCA”), paid Pharmed and AMP the full amount for the false supply orders. To funnel HCA’s payments to the defendants and other uncharged co-conspirators, and to conceal the nature and source of the proceeds, the payments were transferred to two shell corporations, Soho Marketing, Inc. (“SoHo”), and Gator Sports Collectibles, Inc. (“Gator”), controlled by members of the conspiracy. Members of the conspiracy then issued checks from SoHo and Gator to the defendants and other members of the conspiracy and created fraudulent documents to disguise these payments as employee compensation.


Mr. Acosta commended the investigative efforts of the Federal Bureau of Investigation. Mr. Acosta also acknowledged the cooperative efforts of Kendall Regional Medical Center and its sister HCA affiliates for their assistance in this investigation. This case is being prosecuted by Assistant U.S. Attorneys Jeffrey E. Marcus and Ryan K. Stumphauzer.


A copy of this press release may be found on the website of the United States Attorney's Office for the Southern District of Florida at www.usdoj.gov/usao/fls. Related court documents and information may be found on the website of the United States District Court for the Southern District of Florida at www.flsd.uscourts.gov or on http://pacer.flsd.uscourts.gov.

$58 Million Settlement Over Vioxx ....Peanuts!!!

Merck Agrees To $58 Million Settlement Over Vioxx Ad Claims
North Carolina will get $1.8 million from the settlement.

Harrisburg, PA -- Merck & Co. has agreed to pay $58 million as part of a multistate settlement of allegations that its ads for the once-popular painkiller Vioxx deceptively played down the health risks.

The agreement announced Tuesday also calls for Merck to submit all new TV commercials for its drugs to the Food and Drug Administration for review before they can be aired.

The civil settlement ends a joint three-year investigation by 29 states, including North Carolina, and the District of Columbia into Merck's advertising practices involving Vioxx, Pennsylvania Attorney General Tom Corbett said.

Vioxx was taken off the market in 2004 after research showed it doubled the risk of heart attacks and strokes. That triggered thousands of lawsuits against Whitehouse Station, N.J.-based Merck. A pending $4.85 billion settlement would end the bulk of those personal injury suits.

Thanks to aggressive marketing through direct-to-consumer television ads begun in 1999, hundreds of thousands of consumers demanded Vioxx prescriptions before doctors had a chance to understand the side effects, Corbett said.

"Consumers need clear information about the risks associated with prescription drugs so that they can make well-informed decisions about their health care," Corbett said.

The FDA does not require drug companies to submit advertisements for advance approval except in cases where it has pursued enforcement actions over false and misleading claims, agency spokeswoman Rita Chappelle said.

The agreement calls for Merck to submit all new TV commercials for its drugs to the FDA for review and follow through with any changes the agency recommends before airing them for seven years. Additionally, for a 10-year period Merck must comply with any FDA recommendations to delay television advertising for newly approved pain medications.

Merck is also prohibited from "ghostwriting," a practice in which people who worked for the company or were otherwise connected to it allegedly wrote positive articles and studies about Vioxx, Corbett said.

Merck is not admitting any wrongdoing under the settlement and defended its marketing of Vioxx in a statement Tuesday.

"Today's agreement enables Merck to put this matter behind us and focus on what Merck does best, developing new medicines," said Bruce Kuhlik, Merck's executive vice president and general counsel.

Corbett's spokesman, Kevin Harley, said the settlement does not require approval by any court.

Democrats in Congress have intensified their scrutiny of the drug industry, expressing support for tighter regulation of consumer-directed drug advertisements, among other things.

Last year, they tried unsuccessfully to pass a law that would ban such advertisements in the three years after a drug's approval. They are expected to make a similar push later this year.

Most of the settlement cost will be covered by a $55 million pretax charge that Merck said it took in the first quarter. Pennsylvania officials could not immediately provide a breakdown of how the $58 million will be divided.

In February, Merck agreed to pay $671 million to settle claims it overcharged the government for Vioxx and three other popular drugs and bribed doctors to prescribe its drugs. The announcement by federal prosecutors was one of the biggest U.S. health care fraud settlements ever.

In addition to Pennsylvania, the states included in Tuesday's settlement are Arkansas, Arizona, California, Connecticut, Florida, Hawaii, Idaho, Illinois, Iowa, Kansas, Maine, Maryland, Massachusetts, Michigan, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, Oregon, South Carolina, South Dakota, Tennessee, Texas, Vermont, Washington and Wisconsin.

Merck shares fell 26 cents to $39.76 in afternoon trading Tuesday.

Source: Associated Press

Copyright: 2008 digtriad.com

60 miles northwest of Pittsburgh....fraud is everywhere

Clearwater chiropractor sentenced to three years in fraud case
The Associated Press
2:38 pm, April 12, 2008
PITTSBURGH - A former Mercer County chiropractor will spend three years in prison for defrauding an insurance company.

Thirty-eight-year-old Brent J. Detelich, of Clearwater, Fla., was sentenced Friday in U.S. District Court in Pittsburgh. A jury convicted him of health care and mail fraud in March 2007.

Prosecutors say Detelich submitted fraudulent claims to Highmark Blue Cross/Blue Shield for services not rendered. He then split the payments from those claims with some patients.

Detelich did business as Detelich Chiropractic, and Advanced Medical and Holistic of Hermitage, about 60 miles northwest of Pittsburgh.

He must also pay $91,025 in restitution to Highmark. And he'll be on supervised release for two years after his release from prison.

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