Here’s a good article about fraud control in South Africa.

One of the things they talk about is calling patients when a doctor billed more services in a day than he could possibly perform. A key to making that work well is being able to identify outliers immediately and call patients before they forget the service or move. Often analysis like this is not done for a least a month after the claim was paid, which can be long after the service was provided. Having a report within 24 hours of processing the claims (and before th

Around South Florida Fri, Jan. 30, 2004 Miami Herald

“Federal agents Thursday arrested eight Miami-Dade residents accused of spearheading a two-tiered fraud of both the public Medicare system and private automobile insurers to the tune of $5 million.”

Back in August, I said that auto accident fraud rings were also committing health insurance fraud, because they already had the perfect setup. Tacking on healthcare fraud to the accident fraud would be almost pure profit (Accident Ring).

State moves against one of state’s top Medicaid drug prescribers - AP via Florida Times-Union Feb 3 2004 4:27AM GMT [Healthcare Management News]

The State of Florida accused Dr. Armando Angulo of inappropriately prescribing over $2 million of Oxycontin and other narcotics since 2000. According to this article, Dr. Angulo even let clinic staff hand out pre-signed prescriptions on days he was not in the office.

Read my article about Oxycontin abuse

Making Drugs, Shaping the Rules - The drug industry has eagerly helped states set medication guidelines for new antipsychotic medicines. [New York Times Healthcare News]

Whenever I hear about States funding disease management programs with money from pharmaceutical companies I get a little queasy. It feels like having the fox design and build the hen house.

In this article Melody Petersen tells us about how pharmaceutical companies helped pay for development of guidelines that recommend new drugs for the treatment of schizophrenia—drugs that cost $3,000 per year per person, instead of $250. “A Johnson and Johnson subsidiary that sells Risperdal, paid $4,000 to fly two state mental health officials to New Orleans, where they dined at an elegant Creole restaurant in the French Quarter, visited the aquarium and met with company executives and Texas officials,” she reports.

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 - 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.