Robin Mathias's blog

Medicare Considers Curbs on Payment for Cancer Drugs

News and Commentary
Medicare Considers Curbs on Payment for Cancer Drugs - Federal Medicare officials are close to deciding whether to refuse to pay for unapproved uses of expensive cancer drugs. [New York Times Healthcare News] Once the FDA approves a drug for a certain use, doctors can prescribe the drug for other uses, without any evidence that the treatment is effective. This is a big problem in cancer treatment, where patients and their families are often desperate to find a cure. They have the idea that anything is better than doing nothing, no matter the cost (especially if they are not the ones paying for the treatment). In fact, the side-effects of cancer drugs can be far worse than doing nothing, especially given that the drug may not be at all effective.

Costs and Savings in Medicare Change on Wheelchairs

News and Commentary | Fraud Cases | Medical Equipment Fraud Cases | Medicare Fraud Cases
Costs and Savings in Medicare Change on Wheelchairs - Medicare administrators late last fall began to take a closer look at reimbursement requests for power wheelchairs, an effort now saving the government millions of dollars. [New York Times Healthcare News] The beginning of this article talks about the hardships of small businesses and patients who are having trouble getting Medicare to pay for power wheelchairs. Sure, new rules may make it more difficult for everyone to get Medicare to pay for power wheelchairs, but the rules were enacted to control terrible abuse of the system.

February 2004 Newsletter


This Month’s Report:
News and Observations
Steps for Fraud Control
New Look for Website

In the news this morning, I read about Halliburton Co. allegedly overcharging the US government over $16 million for meals at a cafeteria in Kuwait. According to the news reports, they served about 14,000 meals a day but charged for three times as many. This reminded me of the many times I’ve seen healthcare providers billing for services they didn’t provide. It costs the healthcare industry billions of dollars a year.

What is worse is when this same greed leads healthcare professionals to provide services that aren’t needed. In addition to the cost we all pay in higher insurance premiums and taxes, the patient pays in unneeded suffering. Occasionally, providers become especially greedy and get caught performing three times as many open-heart surgeries as their peers, providing thousands of unneeded dental services to kids on Medicaid or conducting unneeded eye surgery on mental health patients. But more often, people are simply snookered.

Fraud News December 2003


Fraud FAQ and Quotes

Reporters often contact me. I put together a list of frequently asked questions and answers that can help journalists respond to tight deadlines for articles about fraud.

Three Million Dollar Medi-Cal Eyeglass Scam

Owners of L&M Diamond Jewelry Optical wer convicted of stealing $2.98 million from Medi-Cal by filing claims for eyeglasses that were lost, stoled or destroyed.

Eyeglasses Scam

Bonus - Free Algorithm

Read about how to create an algorithm to find eyeglasses fraud and other similar abuse. You must login first to access the article. You’ll need to login to the website by entering your username and password in the Client Login menu on the right-hand side of any page of or by visiting user login. If you haven’t registered as a user before, Sign up. This is not the same as signing up for e-news.

Fraud News September 2003


Fraud Forecast Summer 2003

I predict that in the next year we’re going to see a lot more cases involving growth hormones, stolen provider identities, counterfeit drugs, and excessive surgeries. These kinds of cases show that both fraud and fraud control are getting more sophisticated.

Read Fraud Forecast by visiting this link.

Lipitor Fraud and Waste

The cholesterol lowering drug, Lipitor, is an expensive maintenance drug taken by a large percent of the adult population. Most people who take Lipitor have no symptoms. A cholesterol test showed that they have high cholesterol, so they get the prescription. Once prescribed, patients will take this drug until something new replaces it. These factors make it the perfect drug for a pharmaceutical company’s bottom line. They also make it a target for fraud.

Fraud News August 2003


I’ve gathered together some information I think you’ll find useful. If you’ve got suggestions for future topics, please let me know. If you’ve got news you’d like to share, please contact me.

Oxycontin Conviction

Dr. David Mitzan pleaded guilty to charges that he forged prescriptions for Oxycontin and billed his insurance company for the drugs. Oxycontin is a time-released pain reliever that is often abused and is the cause of many crimes.

You can read about Oxycontin by visiting this link

Fraud Control Under-funded

Despite the growing awareness of the vast sums lost to healthcare fraud, most systems fail to allocate fraud control on the scale required by the flow of money involved. Fraud control in the US is under-funded by a factor of 20 or more.

Fraud News May 2003


Pharmacy Kickback Guidelines

How many of your pens have a drug name on them? A pen is not valuable enough to cause suspicion of violating anti-kickback laws, but paying a physician to attend a conference might be. Today the HHS Office of Inspector General released their voluntary guidelines for pharmacy manufacturers. The 56-page document outlines what marketing practices could raise red-flags under federal anti-kickback laws.

Managed Care Fraud Control

Save $7 per $1 Invested There is a myth that there is no fraud in managed care. In fact, a large percent of managed care services are now fee-for-service. For those services, HMOs are at the same risk of fraud as other insurers. For other services, the incentives for fraud are different but still exsist.

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