I'm Back!

Newsletters | Quality

I just returned from the National Association of State Medicaid Directors Annual Conference (NASMD). But when I say, “I’m back,” that’s not exactly what I mean. Many people at the conference expressed disappointment at not receiving enews from me for the past several months. You’ve been wondering what I’ve been up to.

I decided to take a job. Yes, JOB. There are many reasons for my decision, but here’s the one that keeps me inspired. I want to make a positive impact. Yes, idealistic as always, I’m still trying to find ways to make the world a better place. No, I did not join the Peace Corps.

Mathias Method - April 2005


Rules Based Post-payment Analysis allows you to look for known fraud patterns, so you can focus your investigations on the claims most likely to be fraudulent. These systems are also known as Expert Systems, because they are built based on information provided by fraud experts. The systems produce reports that identify providers, patients and claims that fit specific criteria. Each report identifies a particular kind of fraud.

Here’s an example of rules-based analysis:

Providers who order chest x-rays for all patients with respiratory distress.

Robin's Case Spotlight - Feb 2005


In this issue:

  • Database giant gives access to fake firms (MSNBC)
  • West Virginia Prescription Drug Ring Broken Up (WBNSTV)
  • Abuses Endangered Veterans in Cancer Drug Experiments
  • 5 Cases Settled in West Virginia
  • NJ Pharmaceutical Company Employees Sentenced to Prison for Selling Drug Samples
  • MyRxForLess Owners Guilty of Importing Phony Phamaceuticals from Mexico
  • 3 Plead Guilty in $2 M Scheme to Steal Insulin From the Army
  • Former pharmacist pleads guilty to felonies

Mathias Method - January 2005


In this issue:

  • Robin’s Fraud Control Toolbox: GIS
  • Announcements

Robin’s Fraud Control Toolbox: GIS

Geographic Information Systems can be used to dramatically decrease fraud. It can be a great tool to help you: identify geographic areas to focus on, illustrate that fraud occurred, and identify participants in fraud rings.

While we’ve talked about GIS for years, it is currently underutilized as a fraud and abuse detection tool. I think one reason it is not used more is that we are intimidated. But we don’t need to be. We aren’t preparing academic papers, so we don’t have to be perfect. We just need to be able to use the tools well enough to be able to spot potential abuses.

Robin's Case Spotlight - Jan 2005


In this issue:

  • Serono Offered Trips to France
  • Home Health Owners Arrested in Spain Receive Jail Sentence
  • United Health Insurance Settles DME Case

Serono Offered Trips to France

Adam Stupak, pleaded guilty on December 21, 2004 to offering three New York City doctors free trips to France if they agreed to write 30 new prescriptions for Serostim in one week. The illegal promotion was part of Serono’s “$6m-6 Day Plan” to increase demand for Serostim, an expensive drug used in the treatment of AIDS wasting.

2004 Year End Newsletter


This Issue:

  • 2004 Case Highlights
  • 3 Tele-seminars
  • Subscription Changes

2004 Case Highlights

  • Injectable Drugs cases made it to court several times this year. Lupron and Serostim continued to make news. Five urologists from four states were sentenced in the aftermath of a $1.2 million settlement from TAP Pharmaceutical. 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. In additions, Serostim abuse continues to be a problem. Read details

Nov-Dec 2004 Newsletter


Lessons from Crime and Security Experts

Healthcare fraud is basically a security issue. We can learn a lot by looking at security and crime-fighting principles. The credit card industry only loses 6 cents per $100, while the healthcare industry loses at least 6 cents per dollar. We have a lot to learn. This month I’m reading: Beyond Fear by Bruce Schneier (security expert), Crime Fighter by Jack Maple (former NYPD Deputy Commissioner) and Where the Money Was by Willie Sutton (bank robber and jail breaker). These books can teach us many things about fighting fraud. The most important lesson I want you to take away is that fraud is crime and fighting fraud is security.

Sept-Oct 2004 Fraud News


This issue:

  1. Featured Case: eBay Used for Medical Supply Fraud
  2. What to do before you contact the prosecution
  3. 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.

July-August 2004 News


In this month’s issue:

  • Make Fraud Control Everyone’s Job
  • Wheelchair Fraud Update
  • Let’s talk about Data Mining
  • Upcoming Events

May 2004 Newsletter


The Month’s Report:

  • Ten Steps to Stop Healthcare Fraud
  • Fraud Control Toolbox
  • Updated Bidding Opportunities
  • Public Appearances

Ten Steps to Stop Healthcare Fraud

Fraud is a serious problem that affects every healthcare system. Each health plan loses from 3% to 30% to fraud, waste and abuse. Reducing fraud losses is one of the few ways that a health plan can cut costs without hurting their members or providers. Investment in fraud control typically saves $6 to $12 for every dollar spent, yet health systems have not invested in the level of controls that will effectively stop fraud. Check out these ten steps that will help you stop fraud.

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