Friday, December 19, 2008

2 from Athens charged with TennCare fraud; Is this the best Tennessee can do?

Posted: Dec 16, 2008 05:18 PM CST

NASHVILLE (WATE) -- A man and woman from Athens have been charged with 2 from Athens charged with TennCare fraud

Posted: Dec 16, 2008 05:18 PM CST
NASHVILLE (WATE) -- A man and woman from Athens have been charged with TennCare fraud in separate cases.

John V. Davis, 25, is charged with three counts of using TennCare to get controlled substances by doctor shopping.

According to the indictment, Davis failed to disclose to his doctor that he'd seen other doctors within a 30-day period, receiving prescriptions for the painkillers Oxycodone and Hydrocodone.

Investigators say Davis received a prescription for Oxycodone during a visit to a hospital emergency room, which was paid for by TennCare.

They also say Davis used TennCare twice to pay for prescriptions for Hydrocodone.

Kristie Smithers, 31, is charged with three counts of TennCare fraud for using it to pay for fake prescriptions.

Smithers is accused of using TennCare to pay for fake prescriptions written for Hydrocodone three times.

If convicted, each could each spend up to two years per charge in prison.

OIG Releases Reports on Hospital Adverse Events and State Reporting Systems

December 16, 2008
OIG Releases Reports on Hospital Adverse Events and State Reporting SystemsOn December 16, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) released a report entitled "Adverse Events in Hospitals: Overview of Key Issues."

The Tax Relief and Health Care Act of 2006 (Act) mandates that the OIG report to Congress regarding the incidence of "never events" among Medicare beneficiaries, payment by Medicare or beneficiaries for services furnished in connection with such events, and the process that the Centers for Medicare & Medicaid Services uses to identify events and deny payment. According to the OIG, this report is one in a series to fulfill the requirements of the Act.

In this report, the OIG identifies 7 issues critical to understanding adverse events in hospitals. In brief, the 7 issues can be described as follows:

Estimates of the incidence of adverse events in hospitals vary widely and measurement is difficult.
Nonpayment policies for adverse events are gaining in prominence and are viewed as a powerful incentive to reduce incidence but raise potential drawbacks.
Hospitals rely on staff and managers to report adverse events internally, but barriers can inhibit reporting.
Hospitals report adverse events to various oversight entities, although stakeholders suspect substantial underreporting.
Public disclosure of adverse events can benefit patients but also raises legal concerns for patients and providers.
Information to help prevent adverse events is widely available, but some hospitals and clinicians may be slow to adopt or routinely apply recommended practices.
Interviews and literature reveal strategies that may accelerate progress in reducing the incidence of adverse events in hospitals.
On December 16, 2008, the OIG has also released a related report entitled "Adverse Events in Hospitals: State Reporting Systems" in which the OIG identifies and describes state adverse event reporting systems and how states use the reported information. In brief, the OIG reports the following:

As of January 2008, 26 states had hospital adverse event reporting systems and another state had taken action to develop one.
Reporting systems varied in terms of what events were reported, criteria used for selection, and type of information reported.
Most states with systems reported having mechanisms to identify underreporting and strategies to improve reporting.
23 states reported using data to hold individual hospitals accountable and 18 states reported using data to promote learning and prevent adverse events.
In this report, the OIG concludes that state systems are disparate making state adverse event reporting systems data unsuitable for use in the aggregate to identify national incidence and trends. However, the OIG reports that most states use the reported data in similar ways. For instance, states use reports to assess individual hospitals' responses to adverse events, and to promote learning and prevent adverse events.

For purposes of the OIG reports, the OIG expanded beyond the term "never events" to address "adverse events," which describe patient harm resulting from medical ca

Thursday, December 18, 2008

'...Six strategies for waste elimination: ...'

Eliminating Waste in Health Care

The ability to eliminate unnecessary cost is absolutely critical to health care industry. Total spending was $2.3 TRILLION in 2007, or $7600 per person [1]. Total health care spending represented 16 percent of the gross domestic product (GDP). U.S. health care spending is expected to increase at approximately 7% levels for the next decade reaching $4.2 TRILLION in 2016, or 20 percent of GDP [1].

In 2007, employer health insurance premiums increased by 6.1 percent - two times the rate of inflation [2]. The annual premium for an employer health plan covering a family of four averaged nearly $12,100. The annual premium for single coverage averaged over $4,400 [2]. Experts agree that US health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.

So, how health care system can eliminate waste? The results from my research about medication delivery systems conducted over two years at one community hospital provide some answers to this question.

The results are:
• Fifty two out of sixty three nurses (82.53%) highlighted poor training for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
Fifty five out of sixty three nurses (87.3%) reported confusion about their role expectation with respect to medication error reporting and prevention. All technicians stated similar concerns.
Fifty four out of sixty three nurses (85.7%) specified lack of feedback as important factor affecting their psychological safety towards error reporting and prevention efforts. Four out of 6 technicians (66.67%) pointed to the same issue.
• All nurses and all technicians (100%) highlighted productivity pressures as the most stress-generating factor on their daily work averting them from medication error reporting and prevention.
Forty four out of sixty three nurses (69.8%) and three technicians (50%) suggested group behavior influence as another major factor behind poor medication error reporting and prevention.
Forty eight out of sixty three nurses (76.19%) indicated difficulties with utilizing the mechanisms for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.

Therefore, based on the ‘voice’ from the front line staff, I propose the following six strategies for waste elimination:
1) First, healthcare organizations should recognize the growing need to advance the understanding about healthcare delivery systems, unnecessary waste, as well as Quality Improvement (QI) programs by health care professionals. This can be done via continuum education training on systems and QI.

2) Second, health care organizations should start recognizing their frontline professionals as assets rather than costs. It is everybody’s job to eliminate waste and to do improvements. Therefore, the role expectation with respect to waste elimination and quality improvement should be well communicated to all frontline employees and continuously supported by managers and administrators.

3) Third, organization-wide and constructive feedback to frontline health care professionals about QI needs to be provided on a continuous basis. My research found that health care professionals who felt neglected and under-informed regarding the changes often responded with low motivation and discouragement towards QI efforts.
4) Fourth, the productivity pressures, often mentioned by frontline workers as one of the major contributing factors causing the low QI efforts, should be offset by redesigning systems that minimize the unnecessary waste during daily work. This should allow health care professional to devote more time to continuous improvement efforts.

5) Fifth, to remove the undesired group behavior, managers should physically spend more time and effort to establish and support a culture of excellence with high commitment to patient safety, waste elimination and QI.

6) Finally, all unit managers should provide active leadership at the unit floor for promoting standardized behavior with respect to procedural compliance. The goal is to eliminate the variability in the process by creating a culture that values procedural compliance. In additions, promoting procedural compliance by the manager at the unit floor can increase the rate of error recognition and QI efforts via root-cause problem solving, enhance the manager’s reputation for patient safety, and increase the confidence of health care professionals in her/his leadership abilities/skills.

I hope that the proposed implications and discussions will help health care organizations to achieve satisfactory improvement in waste elimination efforts. In addition, I believe that the proposed insights into this area have potential to enhance professional development of health care managers and professionals.

1. Poisal, J.A., et al, Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact. Health Affairs (21 February 2007): W242-253.
2. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2007 Annual Survey. 11 September 2006.

"...recruited homeless people on Medicare and Medi-Cal for hospitalization."

The former head of City of Angels Medical Center pleaded guilty today to his part in a scheme that used L.A.’s Skid Row homeless to defraud Medicare and Medi-Cal. More from KPCC’s Debra Baer.

Debra Baer: Dr. Rudra Sabaratnam pleaded guilty in federal court to two felony counts of paying half-a-million dollars in illegal kickbacks for patient referrals. Prosecutors say he and a co-defendant, who also admitted guilt, recruited homeless people on Medicare and Medi-Cal for hospitalization, even though they weren’t sick. They then billed the government health programs for unnecessary medical care.

Sabaratnam agreed to pay more than $4 million in restitution to Medicare and Medi-Cal. The 64-year-old Brentwood physician faces up to 10 years in prison when he is sentenced in June.


Federal agents raid convalescent home headquarters

Federal agents raid convalescent home headquarters
The Orange County Register
Wednesday, December 17, 2008

Federal agents on Wednesday raided the Mission Viejo headquarters of a national chain of convalescent homes in what company officials said appears to be an investigation into suspected Medicare fraud.

Officials from Ensign Group Inc. said the Department of Justice has been investigating the company since 2006. Greg Stapley, corporate vice president and legal counsel, said the firm may have inherited the problem from its strategy of acquiring troubled group homes.

"We take in a lot of facilities that are in trouble and turn them around," Stapley said.

The U.S. Attorney's Office in Los Angeles could not be reached for comment.

Founded in 1999, The Ensign Group owns and leases 61 convalescent centers in six states, including three in Orange County: Palm Terrace Health Care Center in Laguna Woods; Sea Cliff Health Care Center in Huntington Beach; and Victoria Health Care Center in Costa Mesa. Ensign has a total of 7,400 beds and raised $411 million in revenue in 2007.

According to documents filed by the company with the Security Exchange Commission, the Department of Justice has been looking into the billing and reimbursement practice of some of the firm's subsidiaries.

In 2007, federal attorneys in Los Angeles subpoenaed the firm's bank documents, but later rescinded the demand. The subpoena asked for financial transactions involving Ensign, 10 subsidiaries, an outside investor group and some company officers, said the SEC report.

Later that year, the U.S. Attorney's office sought a meeting with an Ensign employee regarding an investigation into Medicare claims with the federal Department of Health and Human Services Office. The request for a meeting was rescinded, according to the SEC report.

In December 2007, the firm's accounting contractor was subpoenaed and, later, another employee was contacted.

"We believe that the U.S. Attorney may be conducting parallel criminal, civil and administrative investigations involving the Ensign Group and one or more of our skilled nursing facilities," the company said in SEC documents.

The raid on Wednesday was the first formal confirmation of the federal probe.

In November 2006, the company conducted its own internal investigation into Medicare reimbursements and found that documentation was missing for $224,000 in Medicare claims, documents said. These claims have been reported to the federal government, according to SEC statements.

Contact the writer: or 714-796-6930
Legal Advocacy
Supreme Court Refuses to Allow Federal Labeling Law to Shield Against Fraud/Misrepresentation Claims

The U.S. Supreme Court ruled that manufacturers of potentially dangerous products are not shielded from state consumer law merely because their products have complied with federal labeling laws. The specific product at issue in Altria Group Inc. v. Good was “light” cigarettes, but the Court is also considering this term a case that asks whether federal law preempts state product liability claims against pharmaceutical manufacturers for labeling that fails to adequately warn of a drug’s risks.

AARP filed “friend of the court” briefs in both the cigarette and the pharmaceutical case, urging the Court not to preempt state laws because doing so would limit state efforts to protect the health and welfare of their citizens -- allowing consumers who have been injured as a result of a manufacturer’s deceptive practices or faulty manufacturing without a remedy for the harm.

The dispute

Stephanie Good was a smoker who lived in Maine and favored Marlboro Lights and Cambridge Lights cigarettes, believing the marketing claims by cigarette manufacturers that “light” cigarettes were a healthier alternative to regular cigarettes. After learning that the marketing claims were false, she sued Altria and other cigarette manufacturers. She alleged that they had falsely marketed their “light” cigarettes as containing lower tar and nicotine in order to convey to consumers the impression that the cigarettes are less harmful than regular cigarettes. The class action lawsuit argued that in contrast, light cigarettes can actually be more harmful than regular cigarettes due to the cigarettes’ design. The lawsuit alleged that the companies had known this information and had deliberately deceived consumers systematically and over many years.

Plaintiffs specifically invoked the protections of the Maine Unfair Trade Practices Act (MUTPA), which prohibits unfair or deceptive acts or practices in commerce. The defendant cigarette companies argued that their cigarettes complied with federal cigarette safety warning laws and that the federal labeling law preempted the state consumer protection law.

Numerous similar lawsuits have been filed around the country and, faced with conflicting rulings from various courts, the U.S. Supreme Court agreed to take up the matter and resolve this preemption issue.

The ruling

The Supreme Court began with the assumption that the historic powers of states to regulate the health and welfare of their citizenry was not to be disturbed unless Congress specifically intended to do so. It then looked to the enactment of the federal Labeling Act of 1965 (which required cigarette manufacturers to include specific warnings about the potential hazards of smoking cigarettes) to determine whether Congress intended to preempt state labeling laws. Reviewing the many amendments and refinements enacted into law, the Court did find the intent to prohibit states from enacting stronger cigarette labeling laws – but only those laws that specifically addressed the labeling of cigarettes.

The Court was unable to find any support for the argument that state fraud laws were to be preempted. In fact, the court noted in a prior cigarette labeling case, unlike the concerns about wide divergence in labeling that led to Congress limiting state ability to mandate cigarette labels, fraud claims “rely only on a single, uniform standard: falsity.” Or, as AARP’s brief put it, “Make no mistake, this case is about fraud.” Since the MUTPA only addressed fraud and deceit as a general business practice, its general principles were not to be disturbed and defendants were not shielded by the federal cigarette labeling law.

In other words, the Court ruled that federal cigarette labeling law does not protect a manufacturer from liability for breaching the general duty not to lie to the public.

The ruling carries additional significance because the Court is considering this term another case that tests the balance between federal and state law. In Wyeth v. Levine, the pharmaceutical manufacturer is seeking to be shielded from liability because it complied with federal Food and Drug Administration approvals that did not require it to warn of specific dangers. In that case, Diana Levine went to the hospital suffering from migraines but had to later have her arm amputated after doctors intravenously administered a drug that destroyed her arteries. Levine alleged that the drug manufacturer had evidence that if the drug reached arteries, it could cause gangrene but despite this it did not warn of this danger. A jury agreed that the company had failed to warn of risks and awarded her $6.7 million in damages.

At trial and in its appeal, Wyeth argued that it was exempted from state tort law because the federal Food and Drug Administration (FDA) had approved the drug without requiring the warning sought and this preempted state tort law.

AARP’s briefs

In both Altria and Wyeth, the AARP “friend of the court” briefs filed by AARP Foundation Litigation attorneys pointed out that while regulatory agencies impose Congressionally-authorized requirements on manufacturers, those agencies face particular challenges. Both the Federal Trade Commission (which oversees cigarette labeling) and the Food and Drug Administration (pharmaceuticals) are chronically underfunded, often criticized for reliant relationships with industry, and have limited authority over the products -- with very little FTC oversight over cigarettes and extremely limited post-market oversight by the FDA.

Fortunately, there has been another safety net built into the legal system – the traditional tort lawsuit. By imposing the possibility of significant monetary penalties directly on wrongdoers, tort lawsuits incentivize those who develop, make, and distribute potentially dangerous products to do so with the utmost consideration for human health. The tort system plays a critical complementary role with agency regulatory processes to help ensure that items placed into the marketplace are as safe as possible and that any necessary warnings are adequately written and targeted.

The brief in Altria detailed the history of misrepresentation and deception in the marketing of “light” cigarettes, noting the voluminous evidence that has been presented indicating cigarette companies’ knowledge both that smokers were sensitive to health claims and that the health claims were exaggerated. One example of the sensitivity of “light” cigarette consumers: following aggressive health-based campaigns, the market share for “light” cigarettes skyrocketed from 2% in 1967 to 81% of cigarette sales in 1998.

Finally, AARP’s brief pointed out the absurdity of allowing the federal law to preempt state fraud law. Under a theory advanced by one of the defendants, the brief noted, cigarette manufacturers would be shielded from liability even if they made the following claims ”Smoking fights Parkinson’s Disease,” or “Smoking wards off depression.” As the brief put it, “Under Philip Morris’ reading, the Labeling Act – a statute designed to ensure that the public is informed of the risks of smoking – becomes an instrument of deception.”

AARP filed its brief in Altria with other health care and consumer protection advocates. The narrow 5-4 decision is a welcome ruling and could pave the way for further bolstering of state law remedies when the Court turns to Wyeth later this Term.

Contact persons:

Julie Nepveu

Stacy Canan

Miami physician and nurse were sentenced today to 30 years and seven years in prison,

Prison Sentence One of the Longest Ever Received by a Physician in a Medicare Fraud Case

WASHINGTON, Dec. 17 /PRNewswire-USNewswire/ -- A Miami physician and nurse were sentenced today to 30 years and seven years in prison, respectively, in connection with their roles in an $11 million HIV infusion fraud scheme, Acting Assistant Attorney General Matthew Friedrich of the Criminal Division and U.S. Attorney R. Alexander Acosta of the Southern District of Florida announced. The 30-year prison sentence is one of the longest terms ever given to a physician in a federal Medicare fraud case.

Ana Alvarez-Jacinto, 54, and Sandra Mateos, 44, were sentenced today in U.S. District Court for the Southern District of Florida by Chief District Judge Federico Moreno. In addition to their prison sentences, Judge Moreno ordered both Alvarez-Jacinto and Mateos to serve three years of supervised release following their prison term and to pay $8,289,286 in restitution to the Medicare program.

Alvarez-Jacinto and Mateos were found guilty by a Miami jury on Oct. 17, 2008, after a two-week trial on one count of conspiracy to defraud the United States, to submit false claims, and to pay healthcare kickbacks, and one count of conspiracy to commit health care fraud. Alvarez-Jacinto was also convicted of three counts of submitting false claims to the Medicare program.

Evidence at trial established that the defendants worked at Saint Jude Rehab Center, Inc. (St. Jude), a clinic that purported to specialize in treating AIDS patients. Evidence at trial established that St. Jude was operated and owned by Carlos and Luis Benitez, and managed by convicted co-conspirators Aisa Perera and Mariela Rodriguez.

According to evidence presented at trial, in a five-month period between June and November 2003, Alvarez-Jacinto, with the assistance of Mateos, ordered hundreds of medically unnecessary HIV infusion treatments at the clinic. Evidence established that HIV positive Medicare patients were brought to the clinic by Carlos and Luis Benitez for the purpose of receiving cash payments in exchange for allowing the clinic to bill for unnecessary treatments. Testimony revealed that Mateos and other co-conspirators paid the patients cash kickbacks of approximately $150 per visit. After patients had been paid, they agreed to allow Alvarez-Jacinto and her co-conspirators to prescribe unnecessary infusion treatments. St. Jude then billed Medicare for approximately $11 million for the unnecessary services during that five-month period. For those claims, Medicare paid more than $8 million to St. Jude.

"This is a case in which a physician provided unneeded medical services in the form of infusions to actual 'patients' simply to bilk Medicare and make a fast buck," said Acting Assistant Attorney General Matthew Friedrich. "This sentence should send a clear message that health care providers who engage in fraud will not escape accountability because of their professional status."

"False billings to Medicare for services not delivered is a serious crime that depletes our limited Medicare dollars. Far worse, however, is when medical professionals like the doctor and nurse sentenced today, actually order and perform medically unnecessary treatments to pad bills and make more money. Such conduct is inexcusable and will be prosecuted," said U.S. Attorney R. Alexander Acosta.

"Medical professionals are considered respected members of the community, but when that trust is broken, they are not insulated from having to take responsibility for their criminal behavior," said Special Agent in Charge Jonathan I. Solomon of the FBI's Miami Office. "This case demonstrates that those who choose to commit health care fraud, regardless of their stature or position, will be held accountable for their actions "The Office of Inspector General is very pleased with today's sentencing and will continue to aggressively investigate those who defraud the Medicare system. This type of greed, at the expense of our most vulnerable citizens will not be tolerated," said Christopher B. Dennis, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General - Miami region.

After trial, advertising placed in El Nuevo Herald proclaimed Alvarez-Jacinto's innocence and a letter signed by the defendant contained in the advertisement urged members of the medical community to write to the court to support her release from prison. At sentencing, Chief District Judge Moreno found her trial testimony to be perjurious and enhanced her sentence for obstruction of justice.

Carlos Benitez, Luis Benitez and Jose Benitez, were indicted on June 11, 2008, for their role in an HIV infusion and money laundering scheme that totaled more than $100 million for claims submitted by St. Jude and other clinics. The indictment alleges that Carlos, Luis and Jose Benitez were the masterminds of a large-scale HIV infusion fraud operation throughout South Florida involving at least 11 clinics, including St. Jude, and that they laundered the proceeds of their crimes. All three Benitez brothers remain at large.

An indictment is merely a charge, and defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt.

This case was prosecuted by Senior Trial Attorney Charles E. Duross, and Trial Attorneys John K. Neal and Laura Perkins of the Criminal Division's Fraud Section. The case was investigated by the FBI and the Department of Health and Human Services, Office of the Inspector General.

The case was brought by the Medicare Fraud Strike Force (MFSF). The MFSF is a multi-agency team of federal, state and local prosecutors and agents designed to combat Medicare fraud. Strike force operations began in the Miami-area on March 1, 2007. The MFSF is led by Deputy Chief Kirk Ogrosky of the Criminal Division's Fraud Section in Washington, D.C., and the office of U.S. Attorney R. Alexander Acosta of the Southern District of Florida. Since the inception of MFSF operations in 2007, federal prosecutors have indicted 106 cases with 188 defendants in both Los Angeles and Miami. Collectively, these defendants fraudulently billed the Medicare program for more than half a billion dollars.

SOURCE U.S. Department of Justice
Copyright©2008 PR Newswire.
All rights reserved

Department of Health and Human Services had failed to guard some of their confidential information.

HHS Mistakenly Leaks Medicare Recipients' Private Information
By Elaine Grant on Wednesday, December 17, 2008.

This week, thousands of Medicare recipients got an unpleasant surprise when they learned that the Department of Health and Human Services had failed to guard some of their confidential information.
NHPR's Elaine Grant has the story.

Web resources:

New Hampshire Department of Health and Human Services
New Hampshire ServiceLink

New Hampshire Department of Justice
Consumer Affairs Identity Theft Toolkit

It’s open enrollment time for people who use Medicare drug prescription plans, or the so-called Medicare Part D.

Figuring out which drug plan is the best one -- can be confusing enough.
But now there’s an added problem for 93-hundred New Hampshire residents.
The state Department of Health and Human Services says a staffer mistakenly sent their private information to health care providers.

HHS Associate Commissioner Nancy Rollins says the employee sent a routine email about Part D prescription plans to 61 long-term care and home health organizations in the state.

Staffers at those companies use the information to help their clients choose the right Medicare prescription plans.
But, says Nancy Rollins, something went wrong.

Rollinsfacts.wav: Unfortunately the information was contained in an Excel spreadsheet, and it was attached to a workbook. The workbook had a tab and a document that contained information about the 9,300 individuals.

That information included names, addresses, social security numbers and the amount of people’s monthly Medicare Part D premiums.
Rollins stresses that it did not include medical or prescription information.
The department discovered the error on December fourth when a health care provider called them.
HHS immediately called the attorney general’s office, reported the incident and set about trying to remedy the problem.

Rollins1.wav: We contacted the 61 professional health care providers, that included independent case managers home health care providers and so forth and asked them to delete the information and to provide us confirmation that that had been done.

New Hampshire organizations that have had a data breach are required by law to notify the people involved.

On Monday, HHS sent thousands of letters informing people about the incident.
Those letters advise people on ways to avoid becoming a victim of identity theft.
Among those prescriptions: put a fraud alert or a credit freeze on your accounts.
A fraud alert is exactly what it sounds like – it alerts your credit card company to be on the lookout for strange or unlikely charges.
A credit freeze keeps people from checking your credit report, a necessary step when opening accounts or making loans.

It’s a more draconian measure – although it can deter criminals, it can also make it harder for people to open legitimate accounts or to borrow money.
Lauren Noether is a senior assistant attorney general in New Hampshire.

Noetherfreeze: If you know you’re not going to be borrowing any money, you put a freeze on it and that way if someone has your name and social security they’re not opening bank accounts in your name or taking out a mortgage in your name that you may later on be presumed to be liable for.

The Department of Health and Human Services has set up hotlines for concerned citizens.

By early afternoon on Wednesday, almost 300 people had called.
HHS Associate Commissioner Nancy Rollins says the department is still investigating the incident and determining what, if any, disciplinary actions it will take against the employee.She admits that the department did not have policies in place that could have prevented the problem.

Policy.wav: We are addressing the individual issue here, but also looking at if there are policy and protocol ramifications that we need to revisit.

Rollins says participants who did not receive a letter from the department, did not have their name and information leaked.
She adds that if you need help with fraud alerts or credit freezes, you can get assistance from one of 13 Service Link organizations around the state.
Service Links are agencies that counsel seniors and adults with disabilities about long term care.

For help, call the Department of Health and Human Services.
For NHPR News, I’m Elaine Grant

Friday, December 5, 2008

Anti-fraud efforts snagged $1.1 billion in ’ this something to be proud of?

Anti-fraud efforts snagged $1.1 billion in ’07

Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.
Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.

Not sure if this is something to boast about!>?

What about the NCFE case in Ohio? National Century Finance Enterprises, Inc., the largest private fraud case in the history of this country!

In fiscal 2007. the agencies appropriated $166 million from the Medicare trust fund and recovered $1.1 billion

In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion

Posted: December 3, 2008 - 3:00 pm EDT

Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.The program, established by the Health Insurance Portability and Accountability Act of 1996, calls for the agencies to appropriate money from the Medicare trust fund to fight fraud perpetrated against federal health programs. Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.

The dollars returned to the federal treasury as a result included $201 million in criminal fines, $211 million in penalties and damages, and $186 million from disallowed payments identified and recovered through audits. In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion. Money collected on behalf of state Medicaid programs and private payers is not represented in the figures. (See the reports for 2007 and 2006.) -- by Gregg Blesch

Businessman Admits To Fraud With Motorized Wheelchairs

Edem James Etuk, 54, the owner of PMS Medical Equipment Distributors

Etuk admitted that as the owner of PMS, a durable medical equipment company, he participated in a conspiracy that resulted in fraudulent billing of Medicare of approximately $3.8 million.

Medicare paid approximately $1,627,000 to PMS over the course of the conspiracy.

As part of his agreement with the federal government, Etuk has agreed to pay $1,627,053 in restitution to Medicare and to cooperate with the government in its continuing investigation and prosecution of individuals committing fraud against the Medicare and Medicaid programs.

HOUSTON, TEXAS—Edem James Etuk, 54, the owner of PMS Medical Equipment Distributors has pleaded guilty to conspiring to defraud Medicare and health care fraud through a “motorized wheelchair scheme”.

At a hearing before U. S. District Judge Lynn N. Hughes, Etuk admitted that as the owner of PMS, a durable medical equipment company, he participated in a conspiracy that resulted in fraudulent billing of Medicare of approximately $3.8 million.

Prosecutors say that during the course of a 14-month period, Etuk and several individuals, including a Houston doctor presently under separate indictment and pending trial in April 2008, conspired to commit health care fraud, wire fraud and to illegally pay kick-backs in relation to the Medicare program. Etuk admitted he engaged in a scheme to defraud Medicare by billing Medicare for motorized wheelchairs which were either not required by the Medicare beneficiary or not delivered, or both.
Etuk purchased falsified Certificates of Medical Necessity (CMN), which are required to bill Medicare, for $200 each from several doctors. The Medicare beneficiaries in this case were recruited illegally by marketers. Etuk admitted paying Houston marketers for recruiting beneficiaries and even purchased CMNs directly from the marketers for $600 to $1000 each. The fraudulent CMNs were used by Etuk to falsely bill Medicare for approximately $3,880,000 in power wheelchairs and accessories. Medicare paid approximately $1,627,000 to PMS over the course of the conspiracy.
As part of his agreement with the federal government, Etuk has agreed to pay $1,627,053 in restitution to Medicare and to cooperate with the government in its continuing investigation and prosecution of individuals committing fraud against the Medicare and Medicaid programs.
The health care fraud count carries a maximum penalty of 10 years in a federal prison and a $250,000 fine. The conspiracy carries a penalty of five years imprisonment and a $250,000 fine. Parole has been abolished in the federal prison system. Sentencing has been scheduled for Jan. 14. 10-17-07

Hospital admits accepted improper payments from federal health insurance programs for more than five years...and only has to pay 36 mil?

"We expect health-care providers to come forward when they discover issues that could rise to the level of fraud without waiting for us to catch up to them," Fitzgerald said in a statement announcing the settlement.

Hospital settles fraud case for $36M
December 1, 2008 at 11:16 PM | Comments (0)

Condell Medical Center in Libertyville will pay a $36 million settlement to government health programs after the hospital said it accepted improper payments from federal health insurance programs for more than five years, the U.S. attorney's office in Chicago said Monday.

The improper payments, which Condell executives brougto the attention of the U.S. attorney, were uncovered in the process of the medical center's due diligence with Advocate Health Care, which Monday finalized a deal to buy the 283-bed hospital in Lake County for $180 million.

The settlement resolves deals that included improper loans made to physicians, leases with doctor practices that were below fair market value and hospital payments to doctors who performed "patient services without required written agreements," the U.S. attorney's office said in a statement.

Such deals were in violation of federal laws that essentially prohibit hospital payments to doctors for patient referrals. If a hospital, for example, leases space to a physician at below fair market value, that can be construed as a way to encourage doctors to send patients to the hospital leasing the space.

The deals led to millions of improper payments to the hospital from the Medicare health insurance program for the elderly and the state Medicaid health insurance program for the poor. The settlement, which involves improper deals from 2002 through 2007, calls for Condell to pay the federal government $33.12 million to resolve claims related to Medicare and $2.88 million to resolve claims related to Medicaid.

As part of the settlement, the U.S. attorney's office said Condell "does not admit liability and agreed to the settlement to avoid the delay, uncertainty and expense of protracted litigation."

"We regret that in the past Condell may have been engaged in any practices that were not compliant with the law, and remain committed to the highest standards of conduct," said Dennis Millirons, Condell's chief executive officer.

By voluntarily disclosing the illegal relationships and contracts, "Condell avoided a government lawsuit under the federal False Claims Act and was able to negotiate a settlement at a discount," the U.S. attorney's office said. Such a lawsuit could have led to a settlement that would have cost Condell another $10 million or more, according to federal formulas used to calculate health care settlements.

Still, U.S. Atty. Patrick J. Fitzgerald praised Condell "for bringing these practices" to the government's attention.

"We expect health-care providers to come forward when they discover issues that could rise to the level of fraud without waiting for us to catch up to them," Fitzgerald said in a statement announcing the settlement.

--Bruce Japsen

HHS and DOJ Health Care Fraud and Abuse Control Program

HHS and DOJ Health Care Fraud and Abuse Control Program
Annual Report For FY 2007
The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program
Annual Report For FY 2007,
November 2008

"The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS)1, acting through the Department’s Inspector General (HHS/OIG), designed to coordinate Federal, state and local law enforcement activities with respect to health care fraud and abuse. In its eleventh year of operation, the Program’s continued success again confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud or abuse, and to protect program beneficiaries."

Permanent Link Topic(s): E-Government, Government Documents

If only there were also programs like this in developed countries.

Monday, December 01, 2008
Two Important Resources Last month, I was fortunate to be able to attend the 13th International Anti-Corruption Conference in Athens, Greece, where I learned about two important additions to our resources relevant to the issues discussed on Health Care Renewal, specifically to improving integrity and transparency to the manufacture, promotion, and use of pharmaceuticals.

The Medicines Transparency AllianceFormed this year, this group seeks to bring "together at both the international and national levels, a diverse group of people with an interest in the pharmaceutical sector (stakeholders) to find ways to improve information flows, and increase transparency and accountability about the selection, regulation, procurement, sale, distribution and use of medicines in developing countries. By doing so, MeTA will improve how decisions are made about medicines, improve the way they are purchased and supplied, encourage innovative and responsible business practices, and increase the voice of patients and consumers." The Alliance will be focused mainly on developing countries, so that "when a country implements MeTA, it makes a commitment to progressively disclose a standard set of core data covering the quality, availability, price and promotion of medicines. This commitment also includes fully involving civil society, business and other stakeholders to work together to generate, disclose, debate and use these data to help address problems in the pharmaceutical market."

The Alliance has launched programs in Peru and Ghana, and plans to launch programs in Kyrgyzstan and Jordan.

The World Health Organization (WHO) Good Governance for Medicines Programme

This program has been in operation for several years, but seems to have a new and improved web-site. The site notes "Theft, extortion and abuse …the US$ 3 trillion-plus spent on health services worldwide each year are an obvious target for corruption. In fact, Transparency International estimates that 10 to 25 % of global public health procurement spending is siphoned off and stolen. Life-saving resources are being snatched away from the millions of people that need them most. The pharmaceutical sector, with its US$ 600 billion-plus global market value, is vulnerable to fraud." The goal of the programme "is to improve this situation. Guided by WHO’s Medicines Strategy 2004-2007 and launched in late 2004, the programme is raising awareness of abuse in the public pharmaceutical sector and promoting good governance. Its ultimate aim is to ensure that essential medicines reach people - not the black market."

If only there were also programs like this in developed countries.
Labels: Medicines Transparency Alliance, pharmaceuticals, WHO Good Governance for Medicines Programme

posted by Roy M. Poses MD at 11:42 AM

Links to this post

Court approves Medicare freeze on payments to Miami home healthcare companies

Medicare will continue to suspend payments to Miami home healthcare agencies suspected of fraud, according to a November 24 Miami Herald article.
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.

A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.

According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.

Miami Herald article.
By: Compliance Monitor
December 1st, 2008

Condell, the largest health care provider in Lake County, Ill., $36 Million Settlement After Self-Reporting Possible Health-Care Fraud

Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care Fraud

December 1, 2008

Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care FraudCondell Health Network, parent corporation of Condell Medical Center, a 283-bed hospital in Libertyville - after voluntarily disclosing that it received improper Medicare and Medicaid payments - has agreed without litigation to pay the United States and the State of Illinois$36 million as a result of filing false claims for reimbursement, announced Patrick J. Fitzgerald, U.S. Attorney for the Northern District of Illinois. Condell, the largest health care provider in Lake County, Ill., made the voluntary disclosure earlier this year while in the process of being acquired by Advocate Health Care, of Oak Brook, Ill., which was scheduled to be completed today. Full release

Posted by Admin at 02:56 PM

Eight-count indictment for Fabian Aurignac ; health care fraud,...

McAllen Cardiologist Indicted For Health Care Fraud
Monday , December 01, 2008 Posted: 11:46 AM
Suspect faces up to 10 years in prison and fine of $250,000, if convicted

MCALLEN - A federal grand jury in McAllen has indicted cardiologist Fabian Aurignac for health care fraud, acting United States Attorney Tim Johnson announced today. Aurignac, formerly of McAllen, was arrested today in Austin, Texas, where he was to appear before the Texas Medical Board for a hearing regarding the suspension of his medical license. He is expected to make his initial appearance before a U.S. Magistrate Judge in Austin today at 3:00 p.m. The case will be prosecuted in McAllen.

The eight-count indictment, returned under seal Oct. 21, 2008, and unsealed today following his arrest, accuses Aurignac of defrauding the Medicaid and Medicare health care benefit programs by means of false and fraudulent claims in connection with the use of unlicensed, foreign doctors and medical personal and for billing for medical services not rendered. Aurignac, 45, faces a sentence of up to 10 years in prison and a maximum fine of $250,000, if convicted.

The investigation leading to the charges in this case was conducted by the FBI and the Texas Attorney General's Medicaid Fraud Control Unit. Assistant United States Attorney Carolyn Ferko is prosecuting the case. An Indictment is a formal accusation of criminal conduct, not evidence. The defendant is presumed innocent unless and until convicted through due process of law

Monday, December 1, 2008

Medicare by billing for $3.4 million in phony medical infusion services

Medicare by billing for $3.4 million in phony medical infusion services

$1.4 million from Medicare.Fraud Massachusetts

The Patriot Ledger, November 6, 2008
A federal grand jury indicted a Massachusetts man for allegedly scamming about $1.4 million from Medicare. Kingsley Tochukwu Eze, the owner and director of Kings Enterprize in Quincy, MA, was indicted on 14 counts of healthcare fraud, two counts of aggravated identity theft, and a single charge of making a false statement. Eze allegedly submitted false Medicare reimbursement claims for durable medical equipment in 2006 and 2007, according to the indictment.

3 doctors sentenced to prison in health care fraud

ATLANTA (AP) An orthopedic surgeon and two chiropractors were sentenced Thursday to federal prison for cheating insurance companies out of $3 million by mislabeling treatments for back pain.

The sentences are the latest in Georgia to result from a back pain treatment known as Vertebral Axial Decompression.

The U.S. Attorney's Office said Dr. Howard Berkowitz, 58, of Atlanta was sentenced Thursday to 18 months, and the chiropractors, 67-year-old Arthur Hargraves of Douglasville, Ga., and 52-year-old Daniel Puffenberger of Kissimmee, Fla., each got three years and five months.

Berkowitz pleaded guilty and testified against his former partners in the Associated Spinal Care Network, which operated clinics in north Georgia and Tennessee. Prosecutors said the network faked reports to be reimbursed by Blue Cross/Blue Shield of Georgia for the Vax-D procedure, which was not covered by the insurance company.

VAX-D is a non-invasive treatment that uses a mechanical table to stretch a patient's spine. Blue Cross/Blue Shield of Georgia considered it investigational and not medically necessary, and made clear to health care providers that it did not cover the procedure.

The three men were convicted of using a different billing code that pertained to surgical nerve decompression, instead of the specific code assigned to VAX-D, to bill the company for more than $3 million from 2001 through 2005.

On Nov. 10, a federal jury in Atlanta convicted another chiropractor of a similar scheme. His two partners had already pleaded guilty. Another man pleaded guilty in 2005 to the same scheme at clinics in Albany and Columbus, Ga.

In the Northern District of Georgia, seven medical professionals have been convicted, and five were sentenced to a total of over 14 years in prison with monetary judgments topping $7 million.

Saturday, November 22, 2008

Qualifications for a Job in anti-medicare medicaid fraud

Post Date 11/12/2008

Employer WellPoint, Inc

Job Description

TrustSolutions is a wholly owned subsidiary of Government Health Services, LLC, and is part of the WellPoint family of companies. TrustSolutions holds a Medicare Program Safeguard contract with the Centers for Medicare & Medicaid Services to help reduce fraud and abuse in the Medicare Program. Headquartered in Milwaukee, Wisconsin, TrustSolutions also has offices in California, Illinois, Michigan, Virginia, Indiana, Florida and Texas.

Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

Healthcare Fraud Program Director
This position is contingent upon contract award, and can be filled in any of these locations: PA, NY, MD, DC, DE, ME, MA, NJ, CT, RI, NH, VT

Responsible for the development and ongoing management of Medicare and Medicaid Program Integrity anti-fraud programs that are multi-state, multi-function and multi-year in scope. Provides leadership to program managers, project managers and sub-contractors. Typically reports to an executive or senior manager. Program directors typically manage programs, their associated budgets and compliance with contractual requirements that require managing activities and resources of multiple departments or business areas of the organization. Program directors typically support business strategies through an integrated portfolio of programs, projects and initiatives. Essential duties include, but are not limited to: coordinates and manages the development, approval, implementation and compliance of on-going programs; establishes program governance when needed to assure response to issue escalation; develops program budget; ensures program meets its stated objectives; provides subject matter expertise in response to day to day business issues; researches applicable subject matter practices and remains aware of industry trends; manages relationships and partners with corporate and regional business areas; coordinates training related to program; develops program success measures and performs periodic assessments of program success; and performs other duties as assigned.


BA/BS degree and 14 years of experience in related field or an equivalent combination of education and experience or 10 years related experience and a MA degree required with at least 3 years as a manager responsible for managing complex systems and work flows or large contracts for private insurance companies, federal agencies or state agencies related to the detection and prevention of healthcare fraud.
Understanding of complex business processes related to federal contracting required.
Project management experience preferred.
2+ years experience with Medi Medi data
2+ years experience with Medicare Program Integrity Work
2+ years experience with Medicare, Medicaid, or Medi-Medi data analysis
3+ years experience with Medicare claims, including types A, B, C, D, DMEOS, and Regional Home Health
Demonstrated leadership skills and proven planning and organization skills to ensure development and maintenance of relationships across organization is required.

Wednesday, November 12, 2008

Healthcare fraud probes given more resources

Posted: November 11, 2008 - 3:00 pm EDT

The Justice Department’s inspector general found that U.S. attorneys directed more attorney hours toward healthcare fraud, firearms and organized crime than their offices were allocated, while extra positions Congress funded for counterterrorism went unfilled.Offices in large cities were most likely to dedicate more attorney hours to healthcare fraud, according to an audit report examining the resource management of the Justice Department’s 94 U.S. attorneys’ offices. The offices in Baltimore; Dallas; Detroit; the Eastern District of New York, which includes Brooklyn and Queens; Houston; Los Angeles; Miami; and Washington each dedicated two to five times their allocated number of full-time employees for healthcare.
Beginning in fiscal 2006, Congress allocated an additional 43 full-time-equivalent positions to counterterrorism but the inspector general found roughly the same number of attorneys with that focus through 2007 as in 2003. The Executive Office for U.S. Attorneys told auditors that the numbers were partially a result of the timing of the appropriations, inaccurate time reporting by attorneys and fewer terrorism matters referred to the offices than in previous years. Director Kenneth Melson, in a response to the inspector general, notes that U.S. attorneys are appointed by the president and are “afforded significant discretion to manage his or her office according to locally perceived priorities and needs.”

The report, however, finds fault with the data relied on to make decisions and with individual attorney evaluations that are performed infrequently because of budget constraints. -- by Gregg Blesch

Justice Department Announces 2008 Fraud & "Qui Tam" False Claims Act Recoveries...

Posted On: November 11, 2008 by Finch McCranie, LLP

Justice Department Announces 2008 Fraud & "Qui Tam" False Claims Act Recoveries, with Medicare, Medicaid, and Other Health Care Fraud Alone Topping $1 Billion in Recoveries of Taxpayer Funds
Will Wall Street Bailout Produce the Next Round of Whistleblowers Reporting Fraud?

The U.S. Department of Justice this week announced its FY 2008 recoveries in fraud and False Claims Act cases, with more than $1 billion in health care fraud recoveries alone, and a total of more than $1.3 billion. (As explained below, we believe the $1.3 billion figure is low and understates the actual fraud recoveries this year.)

Cases brought by "relators" or whistleblowers under the nation's primary whistleblower statute, the False Claims Act, accounted for 78% of the money recovered. Since the False Claims Act took its current form in 1986, this law has recovered more than $21 billion of taxpayer funds from those who defraud the government.

As health care costs have grown as a percentage of the federal budget, so have recoveries for health care fraud. Recoveries of federal dollars were made because of fraud not only in Medicare and Medicaid, but also other federal programs such as Tricare and the Federal Employees Health Benefits Program.

The largest recoveries were from pharmaceutical companies--Cephalon Inc., Merck & Co. and CVS Caremark Corp. paid more than $640 million. Pharmaceutical fraud cases also repaid $430 million to state Medicaid programs.

DOJ also cited recoveries in cases of fraud affecting defense procurement contracts, disaster assistance loans and agricultural subsidies.

The actual recoveries were greater if you compare DOJ's announcements of its settlements, as well as include dollars recovered under the various State False Claims Acts. (We have written extensively about why states are enacting their own State False Claims Acts to mirror the federal False Claims Act, given the federal law's successes.)

With whistleblowers reporting fraud infecting in the Wall Street bailout funds (because no federal program is immune), it will be interesting to see how these billions of federal dollars show up in future statistics of fraud recoveries.

We have reprinted below DOJ's "fact sheet" about its FY 2008 significant recoveries. We congratulate Justice on another very successful year in fighting fraud and false claims.


Among the Department’s most significant settlements and judgments in fiscal year 2008 were:
• $361.5 million from Merck & Company to resolve allegations that the pharmaceutical manufacturer knowingly failed to pay proper rebates to Medicaid and other government health care programs, and paid kickbacks to health care providers to induce them to prescribe the company’s products. The settlement resulted from two lawsuits brought under the qui tam provisions of the False Claims Act.
In the first, which accounted for $221.9 million of the $361.5 settlement, a former Merck employee alleged that the company violated the Medicaid Rebate Statute by providing deep discounts to hospitals that used its drugs Zocor and Vioxx in place of competitors’ brands, without reporting those discounts and other cost information to reflect its "best price," as required by the statute to ensure that Medicaid obtains the benefit of the same price concessions other purchasers enjoy. This suit also alleged that Merck paid kickbacks to physicians, disguised as fees for training, consultation, and market research, to induce them to prescribe its drugs, also contrary to law. The United States paid the relator $46.6 million as his share of the settlement under the False Claims Act’s qui tam provisions. In addition to the federal recovery, Merck paid $162 million to state Medicaid programs.

In the second lawsuit, which accounted for the remaining $139.6 million of the settlement, a physician alleged that Merck provided deep discounts to hospitals to induce them to administer its antacid, Pepcid, as a means to boost sales through continued use after the patient’s discharge. The suit went on to allege, similar to the first suit, that Merck knowingly failed to report these discounts as required by the Medicaid Rebate Statute, which resulted in illegal and inflated claims to federal and state Medicaid programs. In addition to paying the United States $139.5 million in federal claims, Merck paid $114 million to settle state Medicaid claims. The relator received $24 million as his federal share of the settlement and an additional sum for the state recoveries. Merck also entered into a Corporate Integrity Agreement with the Inspector General of the Department of Health and Human Services (HHS) to ensure compliance with federal health insurance programs in the future.

For the original press release, see:

• $258 million from Cephalon Inc. to resolve claims that the company marketed three drugs for uses not approved by the Food and Drug Administration (FDA). By promoting the drugs for so-called "off label" uses, Cephalon caused providers to charge federal health insurance programs such as Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits Program for unapproved uses of the drugs not covered by the programs. The settlement resolved four lawsuits, three of which were brought by former Cephalon sales representatives under the qui tam provisions of the False Claims Act. Consistent with those provisions, the relators who filed the suits will share $46.7 million as their part of the settlement. In addition to the $258 million recovered for federal programs, the United States recovered $116 million for the Medicaid programs in 14 states and the District of Columbia. Cephalon also pleaded guilty to related criminal charges, paid $50 million in fines and forfeitures and entered into a five-year Corporate Integrity Agreement with the Inspector General of HHS to ensure strict compliance in the future.
For the original press release, see:

• $225 million from Amerigroup Corporation to settle both federal and state allegations that Amerigroup, together with its Illinois subsidiary, systematically avoided enrolling pregnant women and other high-cost patients in the company’s managed care program in Illinois. The program was funded by Medicaid, which required open enrollment to all eligible beneficiaries. By excluding pregnant women and other high-cost patients, Amerigroup increased its profits in conflict with the law. The United States and Illinois jointly brought suit under the federal False Claims Act and the Illinois Whistleblower Reward and Protection Act. In October 2006, following a lengthy trial, the court entered judgment for $334 million. Amerigroup appealed and the parties entered negotiations leading to settlement. The relator received $56.25 million as his share of the federal and state recoveries. In conjunction with the settlement, Amerigroup entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $75 million to settle claims that Kyphon Inc., now Medtronic Spine LLC, violated the False Claims Act by knowingly causing the submission of false claims to Medicare for its kyphoplasty procedure–a minimally-invasive surgery used to treat compression fractures of the spine. The settlement resolved a lawsuit filed by two former Kyphon employees under the qui tam provisions of the False Claims Act. The suit alleged that Kyphon engaged in a seven-year marketing scheme that resulted in certain hospitals billing Medicare for kyphoplasties performed on an inpatient basis rather than for less costly and clinically appropriate outpatient kyphoplasty treatment. This conduct resulted in the Medicare program paying more for inpatient kyphoplasty procedures. The relators received a total of $14.9 million as their share of the settlement. In conjunction with the settlement, Kypon entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $74 million from Staten Island University Hospital (SIUH) to resolve two False Claims Act qui tam suits and two other matters. In the first action, a physician and former SIUH Director of Chemical Dependency Services, filed suit alleging that SIUH fraudulently billed Medicare and Medicaid for substance abuse and alcohol detoxification services provided to inpatients in unlicensed beds, in violation of state law, between 1994 and 2000. SIUH paid the United States $11.8 million in settlement of this qui tam action, with the relator receiving $2.3 million as his share of the government’s recovery. In related allegations of inflated Medicaid billings asserted under New York State’s false claims statute, SIUH paid New York $14.88 million, with the relator receiving $2.97 million as his share of the state’s recovery.
In the second action, the widow of an SIUH cancer patient filed suit alleging that between 1996 and 2004, SIUH submitted false claims to Medicare and TRICARE using incorrect codes for cancer treatments not covered by the programs. SIUH paid the United States $25 million, including a relator share award of $3.75 million. In the third matter, the United States alleged that SIUH deliberately inflated the number of residents it employed to fraudulently increase Medicare reimbursement between 1996 and 2003. SIUH paid the United States $35.7 million in settlement of this matter. Lastly, SIUH paid the United States $1.47 million to settle allegations that it billed Medicare and Medicaid for treating psychiatric patients in unlicensed beds from 2003-2005. In conjunction with the settlement, SIUH also entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $60 million from Lester E. Cox Medical Centers, a health care system headquartered in Springfield, Mo., to settle claims that it violated the False Claims Act, the Anti-Kickback Statute and the Stark Statute between 1996 and 2005. The United States alleged that Cox entered into illegal financial relationships with referring physicians at a local physician group and engaged in improper billing practices with respect to Medicare. Under the Stark Statute, providers such as Cox are prohibited from billing Medicare for referrals from doctors with whom the providers have a financial relationship, unless that relationship falls within certain exceptions. The United States contended that Cox and the referring physicians ran afoul of the Stark Statute, as well as the Anti-Kickback Statute, which prohibits offering inducements to providers in return for patient referrals. The settlement also resolves claims that Cox included non-reimbursable costs on its Medicare cost reports and improperly billed for dialysis services. In conjunction with the settlement, Cox entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $53 million from Pratt & Whitney, a division of United Technologies Corporation, and PCC Airfoils LLC, a subsidiary of Precision Castparts Corporation, to resolve allegations that the companies knowingly submitted false claims for defective turbine blades purchased by the Air Force to retrofit the F100-PW-220 engines found in F-16 and F-15 aircraft. The settlement includes corrective action to replace defective blades and inspection of potentially serviceable blades to ensure their integrity. The case was pursued as part of a National Procurement Fraud Initiative launched in October 2006, to promote the early detection, identification, prevention and prosecution of procurement fraud.

For the original press release, see:

• $26 million from St. Joseph’s Hospital of Atlanta to resolve allegations that the hospital falsely claimed Medicare reimbursement for inpatient admissions that were, in fact, less costly outpatient visits. A registered nurse, formerly employed by the hospital, initiated suit under the False Claims Act’s qui tam provisions. The complaint alleged that the hospital improperly billed for short inpatient admissions, usually of one day or less, when the service should have been billed as an outpatient "observation" or emergency room visit. Medicare reimburses hospitals a higher rate for inpatient admissions than it does for observation care or emergency room visits. The nurse who triggered the investigation received $4.94 million as her share of the recovery. St. Joseph’s entered into a Corporate Integrity Agreement with the Inspector General of HHS in conjunction with the settlement, to ensure future compliance.
For the original press release, see:

• $23.2 million from Bechtel Infrastructure Corp. and PB Americas Inc. to settle allegations of false claims for federal highway funds in connection with the firms’ failure to provide adequate management and quality assurance services during the construction of the Central Artery Tunnel, known as the Big Dig, in Boston. The recovery, part of a $458 million settlement of state and federal claims, resolved parts of a qui tam lawsuit, a related federal investigation and additional claims that Bechtel and PB Americas violated federal and state criminal and civil laws in connection with their services on the Big Dig. In addition to the federal recovery, the companies paid $40 million in state claims and $335 million into a state warranty fund for future repairs to the Big Dig. The private citizen who filed the suit received $54,000 and $96,000 as his share of the federal and state recoveries, respectively.

For the original press release, see:

• $21.1 million from CVS Caremark Corp. to settle claims that from 2000-2006, the company illegally switched patients from the tablet version of the drug Ranitidine (generic Zantac) to a more expensive capsule version for the sole purpose of increasing Medicaid reimbursement. For example, CVS pharmacies in Illinois would charge Medicaid $79.80 for 60 Ranitidine capsules, rather than $17.10 for the tablets prescribed, increasing reimbursement by $62.70 on a single prescription. CVS Caremark is headquartered in Rhode Island and operates more than 6,000 pharmacies nationwide. The settlement resolves qui tam claims under federal and state false claims statutes. In addition to the federal recovery, CVS Caremark paid $15.6 million to 23 states and the District of Columbia. The qui tam plaintiff received $4.3 million as his share of the federal and state settlements. CVS Caremark also entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

Posted by Finch McCranie, LLP

Saturday, November 1, 2008

Here is one person's definition of Healthcare Fraud...a tip of the GLACIER!

Health Care Fraud Costs Billions
October 10th, 2008 · No Comments

What is Health Care Fraud? Health care fraud occurs when health care professionals make false or misleading statements in order to benefit financially. Health care schemes are diverse and often complex.

Examples include overbilling, billing for services not even provided, double billing for the same procedure, billing for a more expensive procedure than actually performed, or billing separately for items that are less expensive when bundled together (for example a group lab tests). It is also fraudulent to receive a “kickback” for referring a patient to another doctor. Doctors have even been caught selling prescriptions to patients for cash.

Part of the reason health care fraud is so prevalent is because health care is so expensive and is such a massive system. It is not unusual for a carrier to cut a check for over $100,000 to someone it does not even know! Because it is so prevalent, billions of dollars are being drained from the Medicaid and Medicare Industries on fraudulent claims. Scam artists often close up shop and flee before investigators can even attempt to recover the fraudulently obtained funds.

However, the Justice Department has made health care fraud a top priority. Many investigations are the result of complaints from patients and the public at large. Because fraud is conducted for the most part “in secret” these tip-offs from health care consumers are extremely valuable to the FBI and other law enforcement officials. Criminal penalties for health care fraud can be very severe. If you are involved in a health care practice you believe may be considered fraudulent, contact an attorney for more information.

Thursday, October 23, 2008

former Minnesota Department of Health and Human Services (DHS) employee ...FRAUD

Aug. 5, 2003, through Sept. 10, 2008, ...$903,896.54 from the State of Minnesota through Medicaid health care fraud.
Hudsonite indicted for health care fraud in Minnesota
Hudson Star-Observer
Published Wednesday, October 22, 2008

A former Minnesota Department of Health and Human Services (DHS) employee was recently indicted by a federal grand jury for health care fraud and for the alleged theft of more than $900,000 in Medicaid funds.

Kim Joann Austen, 47, Hudson was charged Oct. 7 in Minneapolis with one count of health care fraud and 22 counts of theft of health care funds. Her indictment was unsealed Wednesday following her initial appearance in Minneapolis.

Austen turned herself in to authorities Tuesday. Austen remains in custody, and a detention hearing is scheduled for 4:30 p.m. Thursday at the United States Courthouse in Minneapolis.

Austen's indictment alleges that from Aug. 5, 2003, through Sept. 10, 2008, she knowingly and willfully executed a scheme to defraud Medicaid, a federal health care benefit program. It also alleges that Austen used her position to receive $903,896.54 from the State of Minnesota through Medicaid.

Austen had been a state employee since 1981, and had worked in several positions within the DHS since that time. Since approximately August 1997, Austen had been the supervisor of the Medicaid Management Information System (MMIS). The MMIS is a computerized system that processes submitted Medicaid claims for payment.

For more information see the Oct. 30 edition of the Star-Observer.

Wednesday, October 22, 2008

A federal judge today sentenced a Detroit doctor to more than 16 years in prison for health care fraud and pay more than $1.1 million in restitution

A federal judge today sentenced a Detroit doctor to more than 16 years in prison for health care fraud, saying crimes like his are making health insurance unaffordable and threatening the viability of major employers such as the automotive industry.

“I like to find some good in somebody when I sentence them and I find no good in you,” U.S. District Judge Marianne O. Battani told Dr. Zack Brown as she sentenced him to 200 months in prison.

Brown, 61, who was also ordered to pay more than $1.1 million in restitution, was convicted in May of 80 counts of conspiracy, health care fraud and mail fraud for a scheme in which he recruited phony patients to bilk Blue Cross Blue Shield of Michigan, as well as Medicare.


Tuesday, October 21, 2008


"Martin Act was used by the Attorney General with great success in prosecutions of fraud by investment banks, mutual funds and insurance companies. Those efforts led to the recovery of more than $6 billion for investors, businesses and the government. "


New Legislation Would Improve Prosecutors’ Ability to Fight Fraud
Attorney General Spitzer today proposed new Medicaid fraud legislation modeled after the statute he used to bring far-reaching reform to the financial industry.

Spitzer’s proposal, dubbed the "Martin Act for Health Care," removes limitations that hamper prosecution of health care fraud.

"New York State has been a national leader in the recovery of fraudulently obtained Medicaid funds," Spitzer said. "We could do even better if we strengthened the ability of prosecutors to prosecute obvious crimes."

In today’s health care delivery system, approaches to cheating the system by committing fraud have surpassed the dated definitions of larceny. This proposal overcomes the hypertechnical obstacles imposed by current law, and would allow prosecutors to bring cases against Medicaid providers who steal money through half-truths, omissions and deceptions.

The proposal would also help speed investigations and recoveries by providing new investigative tools for law enforcement authorities. For example, one key provision would allow the Attorney General to conduct examinations of Medicaid providers under oath and use the providers’ answers in civil recovery actions.

The Martin Act was used by the Attorney General with great success in prosecutions of fraud by investment banks, mutual funds and insurance companies. Those efforts led to the recovery of more than $6 billion for investors, businesses and the government.
Without Martin Act powers, New York still led the nation in Medicaid fraud recoveries, with $219 million recovered last year. With such powers, the Attorney General believes recoveries would increase significantly.

Spitzer previously introduced several bills aimed at improving Medicaid fraud recoveries and deterring fraud. One would provide financial incentives to those who report incidents of fraud and protects whistle blowers. Another would stiffen penalties for health care-related fraud.

The Attorney General maintains a toll-free tip-line for aid in his fight against Medicaid fraud. To report incidents of fraud or nursing home abuse contact: 866-NYS-FIGHT or (866-697-3444).

Wednesday, October 8, 2008

'Going door to door to sniff out fraud' We must!

Rampant Medicare fraud suspected in Miami
Miami may be ground zero,however this has been going on for years!

By Julie Appleby, USA TODAY
Home health care costs charged to Medicare in the Miami area have risen 20 times the national average in the past five years, prompting a federal investigation of suspected fraudulent billing.
Miami-Dade County is on track to cost Medicare a projected $1.3 billion for home health care services this fiscal year, up 1,300% in just five years, government data show.

SLEUTHS: Going door to door to sniff out fraud
Investigators suspect that fraud is helping to drive the increase because the population of Medicare beneficiaries in the county grew only 10.2% between 2004 and 2007, the latest government data show.

"You definitely have a problem down here," says Randall Culp, an FBI supervisory special agent who oversees a team that works with a Medicare Fraud Strike Force in Miami.

In South Florida, investigators say, some agencies are billing Medicare for millions of dollars in services that are unnecessary, overused or not provided at all.

Investigators elsewhere are paying attention because South Florida is a bellwether for scams that later surface in other large cities, such as Los Angeles and Houston. Scams involving fake AIDS treatments, for example, popped up in Detroit and several other cities after a crackdown in Miami, Culp and others say.

"Typically, Miami is ground zero. Then we see it move to the other high-fraud areas," says Suzanne Bradley, an investigator with the Centers for Medicare and Medicaid Service's field office in Miami.

Home health agencies send nurses and aides to assist homebound elderly and disabled beneficiaries. Nationally, Medicare expects to spend $16.5 billion on home health care this year, up 65% from five years ago.

Medicare spent six times more on home health care services in Miami-Dade County during the first five months of this year than in Los Angeles County, where the Medicare population is three times larger, agency data show.

"It jumps off the page as out of proportion," says Kirk Ogrosky, deputy chief in the Criminal Division's Fraud Section of the Justice Department.

Today, acting Medicare chief Kerry Weems says he will announce new anti-fraud efforts, some targeted at home care agencies in Miami.

"It does affect everyone because everyone is paying into Medicare," says Peggy Sposato, a nurse investigator with the U.S. attorney in the Southern District of Florida, who combs through data looking for unusual billings.

Saturday, October 4, 2008

The Bankruptcy Code Today...

The Bankruptcy Code Today
The present Bankruptcy Code, which became law in 1978, combines three previous reorganization chapters into one, Chapter 11. Chapter 11 is designed to be a flexible tool for the reorganization of the business and debts of corporations, partnerships and individuals. The goals of the reorganization process are many: to maintain the going concern value of the enterprise; to protect workers, their jobs and their retirement benefits; to realize greater value for creditors than a straight liquidation of assets would make possible; to avoid the ripple effects of a failed enterprise. In exchange for opening its books and records, a debtor obtains an automatic stay of any action to commence or continue civil litigation, or to collect an indebtedness, by any creditor in any court anywhere in the United States. Upon the filing of a petition, the previous entity or person becomes a new legal entity, called the debtor in possession, which is charged with fiduciary responsibility for the proper administration of the case for the benefit of creditors and equity holders. A trustee is appointed in a Chapter 11 case only if the debtor in possession is found to have engaged in fraudulent activities or gross mismanagement. The goal and purpose of the reorganization process is the filing of a plan of reorganization that will provide for the repayment of claims on a fair and equitable basis while at the same time permitting the debtor entity to continue its operations.

A reorganization plan must be accompanied by a disclosure statement that has been approved by the bankruptcy court as containing adequate information to enable a creditor to make an informed decision to vote to accept or reject the plan. As in the old composition agreements, confirmation of the plan requires that the majority in number but only two-thirds in amount of creditor claims in each impaired class must vote to accept it. If a debtor is unable to achieve the requisite number of votes to obtain acceptance of its plan by the acceptance method, it may ask the court to confirm the plan over the objections of creditors. The court must evaluate whether the plan is fair and equitable and does not discriminate unfairly with respect to each class of claims impaired under the plan. Upon confirmation of a reorganization plan, property of the estate vests in the reorganized debtor, and the plan becomes a new contract between the debtor and its creditors.

Chapter 11 reorganization has come to be seen as the vehicle of choice for addressing mass tort claims. Cases have been filed, for example, by manufacturers of asbestos-containing building materials, Agent Orange, and the Dalkon Shield birth control device. The focus of these cases was the development of a process that would permit all interested parties, including victims, lenders, debtors and shareholders, to come together to develop an equitable method of compensating victims while permitting the debtor to continue in operation. The formation of various official committees, each with its own advisers, facilitates the process.

Chapter 11 and the U.S. Catholic Church
These are the principles that have led to the filing of the diocesan reorganization cases. In each case, the bishops have cited the need for a process that permits equitable and compassionate treatment of victims while permitting the diocese to return to its role as a church. From its first pages, the disclosure statement in the Tucson case emphasizes that the purpose of the filing was to “fairly, justly, and equitably compensate the victims of sexual abuse by clergy or others associated with the Diocese and bring healing to victims, parishioners and others affected by the past acts of sexual abuse committed by clergy and others while allowing the Diocese to continue its ministry and mission.” The proposed plan provides for the creation of two trusts to be funded by settlements from insurers and the liquidation of certain diocesan assets, exclusive of parish and school property. Trustees for each of these trusts are to be given responsibility for resolving all pre-petition tort claims, investing and managing settlement funds, and making payments to holders of allowed claims.

One issue that has received much attention in these cases is whether the assets of the parishes are assets of the bankruptcy estates. While it does not define property rights, the Bankruptcy Code does prescribe which assets become property of the bankruptcy estate upon the filing of a petition for relief. Property of the estate is very broadly defined to include “all legal and equitable interests of the debtor in property as of the commencement of the case.” There are certain exceptions to this broad definition. Property of the estate does not include property in which the debtor holds, as of the commencement of the case, only legal title and not an equitable interest. Pursuant to canon law, all clerics and lay persons who take part in the administration of ecclesiastical goods are bound to fulfill their functions in the name of the church according to the norms of law. But the Code of Canon Law does not specify how title to the temporal goods of the church is to be held, and the practice varies from state to state.

It has been argued that pursuant to canon law, the bishop’s interest in parish assets is a bare legal title and that parish assets are therefore not property of a diocese’s bankruptcy estate. This is far from clear, however, and trial and appeal of this issue could take years. But through the plan negotiation process, it may be possible for interested parties to agree upon an adequate amount to fund a plan in lieu of liquidating parish assets. Victims and parishes, through their representatives, may fully participate in the plan negotiation process.

Other questions have arisen about the role of the bankruptcy judge in supervising diocesan activities and the administration of diocesan assets, and whether this would impermissibly interfere with the free exercise of religion. In point of fact, the bankruptcy judge has no responsibility for case administration under the present Bankruptcy Code. That role is placed upon the trustee. While it is possible under the Bankruptcy Code for a judge to appoint an operating trustee for a nonprofit debtor in the event of gross mismanagement or fraud, it is more likely that a judge would first address specific creditor concerns through the appointment of an examiner. An examiner may be a lawyer or an accountant, but need not be, and is charged with investigating allegations concerning fraud, dishonesty, incompetence, misconduct, mismanagement or irregularities in the management of the affairs of the debtor, and with making a report of his findings to the court and other interested parties. If the report of the examiner reveals the need for the appointment of a trustee, a person is elected to serve as trustee by non-insider creditors holding allowable, undisputed, fixed and liquidated unsecured claims.

In a Chapter 11 case, however, there ordinarily is no trustee. Rather, the debtor in possession is clothed with the rights, duties and powers of a case trustee. So long as a diocese remains in possession of its property, the bishop of that diocese, together with his consultors, will continue to make decisions concerning the operation of the diocese. While a debtor may not use, sell or lease property outside the ordinary course of its business without the approval of the bankruptcy court, this approval is routinely given where there are no objections to the proposed action by affected parties. Whether in connection with obtaining confirmation of a plan or during the administrative phase of a case, the role of the bankruptcy judge is limited to deciding whether a proposed action does or does not meet the requirements of the Bankruptcy Code. In deciding that question, the judge generally has no power to compel an alternative action.

Bankruptcy law is certainly not the solution for all problems, and I am not urging a rush to the bankruptcy courts. But more Catholics need to become familiar with the reorganization process and value it for the creative solution it can provide for some very difficult problems now being faced by the church in the United States.

Jennie D. Latta is a United States bankruptcy judge for the Western District of Tennessee.

Link NCFE to Financial and Healthcare FRAUD!

All you have to do is go to the trial currently in Colimbus Ohio, NCFE>
You can verify the link between the financial and healtcare industries.

No doubt one of the leading issues in this election is the question of health care coverage. For working Americans apart from losing their job there is no greater fear than inability to pay for their health care costs. Each year the number of working Americans who are uninsured gets closer to 50% and even for those that have some form of coverage it is often inadequate to their needs. The Democratic and Republican Plans are significantly different in their ways to address this issue. Which is better prescription for America?

First lets clarify what are the current problems?

Note enough people are currently covered by any plan.Any solution has to significantly include basically the whole of the population. We can longer have a system of “charity’ that assumes that providers and hospitals will donate to the needy. This system assumes the old concept of ability of pay based upon an individuals income is still in place. By definition for it to work requires that those who can pay more will pay higher prices to subsidize the care of the uninsured or under insured. This has created a disaster in health care because it makes it impossible to know what are the real prices in health care. How did it ever occur that private payers, Medicare, and health insurance can pay very different fees to the same provider for the same service. Most of the people who have health insurance are over the age of forty. The system will always be under capitalized unless the vast majority of young workers begin paying into system which is the major problem with a program that leaves too many not participating. For this reason the concept that Hillary Clinton recommended of “pay or play” is a sound construct.

Coverage varies widely too much between plans. Consumers cannot compare pricing of insurance plans because there is no real standard for what the term ‘insurance’ means. The reality is that none of us can ever be correct about what predicting our future medical expenses will be. Opting for a ‘cheap’ high deductible plan even for a healthy 20 year old can be a nightmare if out of the blue he or she is suddenly involved in a major automobile accident or delivers a premature baby. To call something a legal medical insurance plan means that it has to cover major conditions reasonably well within the income of the individual covered. Who is going to oversee this to prevent another crisis similar to the subprime loan fiasco?

Making health insurance job based limits the consumers options for alternatives and creates problems when there is a change in the job status.
The current system of job based insurance began during World War II as a simple way to give the public coverage who mostly worked in large war related industries. It did not envision that a majority of Americans would be working for small business or that adults may change jobs seventeen times or more in a lifetime. Labor unions played a great role in advocating the need for health care of their workers and often health care benefits become the key point of corporate-labor negotiations. But now it plays too much of role in the fight of whether labor should be unionized or not. The American auto industry has been rendered severely non-competitive by high health care costs which would be lower if they were shared in a larger risk pool than just one company or industry. McCain is right in not making health insurance job based.

The economy is weak and there is limited funds for health care. Every year our society gets older and our medical technology gets more expensive. Although health care is a necessity for a civilized nation it is not an industry that really improves the overall production of wealth. We can only expend so much of our overall budget as a nation on health care. Expense or overpriced treatments that are not proven to be clearly of value cannot be afforded. We have to mandate more complete coverage for proven effective treatment of conditions which are life threatening and minimize or exclude coverage of unproven treatment of conditions which are unlikely to benefit from such treatment. While many people cannot get enough coverage for the treatment of cancer, billions of dollars are wasted every year in operations and treatment of chronic pain conditions that are likely of no real benefit. However, one cannot be an advocate for health care without understanding that the most important single factor in determing whether health care is affordable is the health of the economy.

There are conflicting reports from recognized “think-tanks” about which plan would be best.

To evaluate the candidates’ proposals, the Commonwealth Fund Commission identified “several key principles for moving the health system toward high performance. They include:provision of equitable and comprehensive insurance for all;provision of benefits that cover essential services with appropriate financial protection;premiums, deductibles, and out-of-pocket costs are affordable relative to family income;health risks are broadly pooled;the proposals should be simple to administer, with coverage that is automatic and continuous;dislocation should be kept to a minimum—people could choose to keep the coverage they have; and financing should be adequate, fair, and shared across stakeholders.” Measured against these broad principles,they continue, Obama’s proposal for mixed private–public group insurance with a shared responsibility for financing has” greater potential to move the health care system toward high performance than does McCain’s proposal to encourage individual market coverage through the use of tax incentives and deregulation. Compared with McCain’s approach, Obama’s approach could provide more people with affordable health insurance that covers essential services, achieve greater equity in access to care, realize efficiencies and cost savings in the provision of coverage and delivery of care, and redirect incentives to improve quality. In the absence of a requirement that everyone has affordable coverage, however, the proposal is likely to fall short of achieving universal coverage.”

Robert E. Moffit, Ph.D., is Director of the Center for Health Policy Studies at The Heritage Foundation says the Obama Plan is “Not the Right Prescription”. He states “Proponents of government competition in a “national health insurance exchange” claim that it would enhance personal choice and health plan competition. That is highly unlikely. Rather, such a system would impose federal control over virtually every aspect of private health insurance, rendering it virtually indistinguishable from government insurance except for its direct financing. Congress would become increasingly prescriptive over benefits, the adoption of medical technology and new medical procedures, the pricing of these items, and the mechanism that plans may or may not use to manage health care risks. In other words, hardly any aspect of private health plans’ business operations would be free from government regulation and control. That is not a prescription for health care choice or competition.”

In my opinion, there is good and bad in both the McCain and Obama plans. Unfortunately, neither plan really addresses the most important issue of determining how much money will be paid for what. The medical system as it is currently structured is filled with waste and maybe some fraud. The Wall Street financial crisis may be a mouse compared to the elephant of the health care industry. Many health care insurance CEOs are actually even better paid that Wall Street executives. These days the most expensive car in the “doctor’s parking lot” does not belong to the heart surgeon but usually the hospital administrator. Even if you believe that physicians are over paid, many studies have shown that given the number of years of training and hours worked they are not, there is no doubt that nurses are severely underpaid. Yet some of the fastest growing salaries in America are those of health care executives at every level which more often than not have nothing to do with performance. Physicians must be allowed to develop appropriate standards of what care should be covered in the same manner that has resulted in the Veteran’s Hospitals going from once being thought of as substandard to now being leaders in the care of chronic conditions such as diabetes.

At the same time I agree with Dr. Moffit that making the government a competitor against insurance companies will serve no purpose.The biggest obstacle to private health care is the fact that it is appropriately a right. Mandated services to the public such as fire departments, schools, and garbage disposal must be highly regulated and overseen if they provided privately. For these types of services there is a very real issue as to whether competition is necessary or functional. Health care by definition cannot really be a “profitable” venture because it does not produce wealth it is a social good. Fostering competition in the American health care community has resulted in too many hospitals being too close together with many redundant services. Does it make sense for every doctor’s office to have its own office equipment, waiting room, and billing staff which add significantly to their overheads. False notions about competition make it very difficult for doctors to deal with insurance companies because of anti- trust laws.These types of administrative costs add trillions to the overall cost of health care and tend to make hospitals general centers of overall care but limit the possibility of creating real regional center of expertise.

Finally as Sarah Palin said in the recent Vice-Presidential debate, there is the issue of personal responsibility. As a retired physician who has practiced not only in the United States but visited in other countries I have seen that Americans are unique in demanding often unnecessary services. Injured workers go to court to ask for thousands of dollars for massage treatments that no one really feels will be of any benefit. Many chronic conditions are treated with drugs and therapy treatments which are no more effective than placebos. Obesity, smoking, alcohol abuse, and reckless behavior are more than just a drop in the bucket of overall health expenditures. Americans have to think of themselves as being members of a large extended family with only one budget that needs to be used for the good of us all and not the gluttony of one.

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