Here’s a question I saw at the ACFE forums:
We’re a self-insured entity, so when it comes to insurance fraud, we’re ultimately the victim. Here’s an example: I get a tip regarding an employee who is allegedly committing fraud. Since we don’t directly administer the plan, I don’t have any records regarding the transactions. What could the plan administrator legally share with me in terms of documentation of the situation?
I thought non-ACFE people would be interested in my response:
One of HIPAA’s purposes is to keep employers from having health information that could be used to discriminate against their employees. Here’s what you need to do to protect yourselves from healthcare fraud without running into problems with HIPAA:
While this is not about healthcare fraud, it shows that creative use of resources can help solve cases. One way of using Google to find fraud is to search for keywords related to illegal marketing practices. For example, you could search for “free chiropractic exams.” The first article I found was My Visit to a Straight Chiropractor, which is an excellent article about a visit to the chiropractor in response to a telemarketing call. It gives a great explanation of the kinds of scams we’re looking for.
Dr. Alan I. Aronowitz was sentenced this week to four years in jail and ordered to pay $200,000 in restitution to United Concordia insurance after pleading guilty to using unlicensed assistants to perform root canals.
Aronowitz’s lawyer had argued that white-collar criminals should not get jail time.
There’s an attitude that poor people should go to jail, but wealthy educated people should do community service.
“The lawyer is implying that fraud isn’t so bad,” says Robin Mathias, a healthcare fraud control specialist. “There’s an attitude in this country that if a mother steals to feed her kids and pay the rent, she should go to jail, but if a wealthy person steals to get a vacation home, that person should just do community service. This attitude increases healthcare fraud not only because perpetrators think they are unlikely to go to jail if caught, but also because they often convince themselves that what they’re doing isn’t wrong.”
Dr. Joseph Olstein helped the government get a $1.2 billion settlement from TAP Pharmaceutical and AstraZeneca. In return he received only a light sentence for his part in the scam. The US Attorney announced that Olstein was sentenced this week to one year probation and a $20,000 fine (in addition to a previous $50,000 restitution payment).
Dr. Olstein pleaded guilty in 2001 to billing insurance companies for free samples of Lupron, which he received from TAP sales people. Lupron is an injectible drug used for treating prostate cancer. Physicians can bill Medicare and other insurers for injectible drugs. Because the free samples were given as a way for physicians to enhance their income, the samples are considered a kick-back. Without the kickbacks that TAP offered to urologists, an equivalent drug that is cheaper than Lupron would probably have been prescribed.
Two owners of a South Florida treatment center for infectious diseases, a physician at the center and a nurse who served as its administrator, were arrested for their roles in a costly Medicaid fraud scheme, according to an October 1, 2004 press release from the Florida Attorney General. The scheme involved billing for prescriptions for medications that were never dispensed and the creation of false medical records to conceal the doctor’s absence from patient treatment and office supervision. Medicaid investigators seized over $1.6 million in illegally purchased assets, including a 40-foot boat, an ocean-view condominium, and a Cadillac SUV.
“It’s all about the money,” was the operating creed of Hatch Dental, as described in a 42-count felony complaint filed by California Attorney General Bill Lockyer on September 22, 2004. The complaint describes how 20 defendants affiliated with three Hatch Dental clinics let greed rule their practice at the expense of patient health and safety.
In spring of 2002, when Brian Kanarek, DDS asked defendant Kyon Maung Teo (the alleged ringleader) why he over-diagnosed treatment, Teo told him, “Something has to pay for this practice.” After Kanarek diagnosed only 2 fillings for a patient whom Teo diagnosed 26, Teo told him to leave Hatch Dental “and don’t come back.”
- Featured Case: eBay Used for Medical Supply Fraud
- What to do before you contact the prosecution
- States up in arms over Payment Error Rate Measurement Rule
1. eBay Used for Medical Supply Fraud
In Washington last week, deputies arrested Sally Hansen after they caught her selling medical supplies on eBay. The supplies were allegedly paid for by Washington state for Hansen’s disabled child. The Seattle Post-Intelligencer reported thta the state Department of Social and Health Services paid $15,100 for diapers, fruit drinks, and PediaSure, and a state employee health insurance program paid about $23,000 for medical supplies for Hansen’s daughter.