Any test which doctors provide themselves (self-referral) is an opportunity for fraud. To identify suspect cases, measure the number of tests per 1,000 patients for doctors performing the test themselves, compared to those who refer patients to another provider. You may need to make adjustments for patient diagnosis or health status.

Of course looking to evidence is most important. Are these doctors qualified to perform the service? Is the diagnostic test effective as a screening tool or should its uses be more limited? Does the test result in more treatment? Is the treatment effective?

Here are some highlights from an article from the New York Times about a product with high fraud potential:

According to the article by Judith R. Tackett, TennCare is increasing their focus on beneficiary fraud through their new Office of Inspector General:

“Faulkner, who was appointed by Gov. Phil Bredesen in July 2004 to establish the state’s Office of Inspector General, said Tennessee is ahead of the game when it comes to fighting TennCare fraud. Her office targets TennCare recipients committing fraud while the TBI concentrates on provider fraud.

After string of successful fraud prosecutions, Sullivan takes on medical device makers

BY JEREMY OLSON

Pioneer Press

A watchdog of the pharmaceutical industry is turning his attention to the marketing practices of the medical device industry.

Michael Sullivan, the U.S. attorney for the Massachusetts district, has earned more than $3.3 billion for the federal government through health care fraud lawsuits. His biggest cases challenged whether drug makers used kickbacks or other improper methods to sell their products.

From the North Country Gazette:

“The owner of a Westchester County transportation company has admitted to stealing more than $400,000 from the state Medicaid program by fraudulently billing for hundreds of rides that never took place and for rides that were not authorized by medical practitioners.

Meir Sassoon, president of Saswitz Corporation, appeared before Westchester County Court Judge Rory J. Bellantoni, on Sept.1 and pleaded guilty to every count of an indictment which charged him with one count of grand larceny in the second degree and 25 counts of offering a false instrument for filing in the first degree. The defendant agreed to make full restitution to the New York State Medicaid program, in the sum of $437,845.51, before sentencing on Sept. 28.. Saswitz Corporation previously pled guilty to grand larceny in the second degree.

Utah doesn’t take health fraud lightly

People who cheat on insurance are hit with federal charges

By Pamela Manson
The Salt Lake Tribune

As part of his divorce settlement, James K. Bond was ordered to pay for health insurance for his former wife. He allegedly took the cheap way out.
For almost five years after the divorce, authorities contend, the Utah man stayed married on paper - listing his ex-spouse as his wife on his Salt Lake County employer’s health insurance plan, allowing her to keep submitting claims.

SAN ANTONIO - A medical supply company owner was sentenced to a year and a half in jail and ordered to pay $1.3 million in restitution. In December he pleaded guilty to falsifying Certificates of Need for medical supplies.

GREENEVILLE, Tenn. — Mailee Renae Lodge (AKA Mailee Renae Reed) was ordered to pay $1.3 million in restitution for cheating Medicare by filing false claims. She was sentenced to five years in prison. She and her husband used a stolen provider id to fraudulently bill for home examinations, sleep studies, pulmonary studies and other procedures.

Please do not contact me with questions about this RFP. I’ve posted this link as a courtesy, since I know people often visit my site looking for information about MMIS RFPs. The purpose of this RFP is to receive proposals from qualified vendors wishing to provide services required by Florida Medicaid to design, install, and operate a Medicaid Management Information System, Decision Support System, and fiscal agent services. The Medicaid Procurement Library is available from the Agency upon request. The RFP is available on paper and electronically on CD-ROM upon request. A Vendor Conference has been scheduled for 1:30 PM, March 23, 2005, at 2727 Mahan Drive, Building 3, Conference Center, Tallahassee.

First of many? Vaccine probe may extend beyond Connecticut

Byline: Mark Taylor

This is an excerpt. Click the link to view the full document.

Last week’s settlement by a Connecticut hospital could be just the first as state Medicaid fraud-control units explore allegations that hospitals, physicians and other providers may be billing Medicaid and private insurers for children’s vaccines they received free, according to government sources and healthcare fraud experts.

Healthcare billing fraud consultant Robin Mathias, former director of data analysis and budget for Indiana’s Medicaid program, said the vaccine billing scheme has likely spread beyond Connecticut’s borders.

“Regardless of what the federal agencies are saying, I suspect that other Medicaid programs will be looking into whether they’ve been billed for the VFC free immunizations,” said Mathias, who advises health plans about fraud schemes. “Whether or not it was fraud or an honest error, those providers would have been essentially paid twice for the same service, and that’s illegal.”

She said hospitals, many of which operate outpatient, immunization and community clinics, could face liability.

This girl was fed by a feeding tube for the first 7.5 years of her life because of a misdiagnosis. How did this happen? Surely they should have gotten an independent 2nd diagnosis long ago.

How sweet it is/Girl eats real food for first time in 7 1/2 years after doctors at Stanford solve mystery

Dave Murphy, Chronicle Staff Writer

From the time Tilly Merrell was a year old, doctors told her family she
would never have a normal life — or even a normal meal.

British doctors found that the food she swallowed went into her lungs
instead of her stomach, causing devastating lung infections. They said she
had isolated bulbar palsy, and their solution was to feed her through a
stomach tube. Forever.