Detroit: Medicare Fraud Summit Preventing Health Care Fraud Panel

OUR NEXT PANEL IS THE ROLE OF PROVIDERS IN
PREVENTING HEALTHCARE FRAUD.
THIS IS AN IMPORTANT COMPONENT OF OUR
MULTIPRONG STRATEGY FOR FIGHTING HEALTHCARE
FRAUD BENEFICIARIES, LAW ENFORCEMENT, AND OUR
PARTNERS IN DELIVERING SERVICES TO MEDICARE AND
MEDICAID BENEFICIARIES, OF COURSE, OUR PROVIDERS
AND SUPPLIERS. I HAVE A VERY
INTERESTING PANEL WITH US TODAY.
CLOSEST TO ME IS VICKI NEAL WHO IS THE AREA
DIRECTOR OF THE NATIONAL INSURANCE CRIME BUREAU
FOR AREA OPERATIONS. NEST TO HER IS
DR. MARTHA POLLOCK, WHO IS THE CORPORATE MEDICAL
DIRECTOR OF INTEGRATED HEALTH SERVICES.
AND TO HER RIGHT, DR. ALBERT VILLARIN WHO
IS THE DIRECTOR OF PHYSICIAN SERVICES AND
CYNTHIA WISNER, ASSOCIATE COUNCIL OF
TRINITY HEALTH. I'M GOING TO START OFF
WITH A BRIEF PRESENTATION OF THE
INNOVATIVE ACTIVITIES THAT ARE GOING ON UNDER
OUR AUSPICES AT THE CENTERS FOR MEDICARE &
MEDICAID SERVICES. A LOT OF WHAT YOU HAVE
BEEN HEARING HAS BEEN GOING ON WITHIN OUR LAW
ENFORCEMENT COLLEAGUES AND OUR WORK WITH THE
BENEFICIARY COMMUNITY. WE'RE ALL IN THIS IN A
VERY WELL ORGANIZED AND COHERENT COLLABORATIVE
EFFORT. I'M GOING TO DESCRIBE A
COUPLE COMPONENTS OF THAT TO YOU NOW.
THIS IS WHAT WE'RE DOING DIFFERENT IN THE
MEDICAID AND MEDICARE AGENCY.
WE'RE MOVING FROM AN HISTORICAL WAY OF
ATTACKING FRAUD KNOWN AS PAY AND CHASE WHERE WE
PAY CLAIMS QUICKLY WHERE WE SHOULD DO FOR
LEGITIMATE SUPPLIERS, AND THEN WHEN THERE WAS
A PROBLEM, WE WOULD WORK WITH THE PROVIDERS AND
SUPPLIERS AFTER THE FACT TO RECOVER ANY
DISCREPANCIES. THAT DOESN'T WORK WHEN
YOU'RE DEALING WITH THE NEW KINDS OF CRIME
ELEMENT, CRIMINAL ELEMENTS THAT WE'RE
DEALING WITH, WHO AREN'T THERE WHEN YOU CHASE
AFTER THEM AND EVEN IF YOU DO FIND THEM, THE
MONEY IS GONE. THE SECOND LINE IS VERY
IMPORTANT. WE ARE FOCUSING OUR
EFFORTS BASED UPON THE ACTUAL RISK OF FRAUD.
WE'RE NOT TREATING EVERY ONE THE SAME.
WE'RE NOT TREATING PROVIDERS WHO HAVE
BILLING ERRORS THE SAME AS WE'RE TREATING
ORGANIZED CRIMINAL SCHEMES.
AND TO DO THIS, WE NEED TO TARGET WHAT WE'RE --
OUR INTERVENTIONS AND I'M GOING TO TALK ABOUT
AN EXAMPLE OF THAT IN JUST A COUPLE OF
MINUTES. THAT EXAMPLE INCLUDES
MANY OF OUR INNOVATIVE ACTIVITIES THAT WE'RE
DOING, IN PARTICULAR, LOOKING AT THE USE OF A
VARIETY OF SOURCES OF INFORMATION IN A WAY
THAT WE WERE NOT DOING IN PREVIOUS TIMES.
WE'RE BEING MUCH MORE OPEN. THIS
ADMINISTRATION IS VERY COMMITTED TO
TRANSPARENCY AND ACCOUNTABILITY.
AND WE'RE DEVELOPING PERFORMANCE MEASURES TO
SEE WHETHER OR NOT WE ARE ACHIEVING THE GOALS
THAT WE ARE SETTING OUT TO ACHIEVE.
THE IMPORTANT WORK THAT WE'RE UNDERTAKING IS NOT
THE GOVERNMENT ALONE. THE SAME PROBLEMS ARISE
IN THE PRIVATE SECTOR. AND WE ARE VERY MUCH
COMMITTED TO A PUBLIC PRIVATE PARTNERSHIP IN
FIGHTING HEALTHCARE FRAUD AND WE'RE MOVING
FORWARD IN THAT DIRECTION SUBSTANTIALLY.
FINALLY, UNDER SEBELIUS SECRETARY'S LEADERSHIP,
WE HAVE CONSOLIDATED MEDICAID AND MEDICARE
PROGRAM INTEGRITY ACTIVITIES FOR THE FIRST
TIME UNDER THE SAME ROOF AND THAT IS, THE CENTER
FOR PROGRAM INTEGRITY THAT I HAVE THE
PRIVILEGE OF LEADING. ALL OF THESE REPRESENT
THE NEW DIRECTION WE'RE GOING IN AT THE CENTERS
FOR MEDICARE & MEDICAID SERVICES.
WE HAVE ACTIVITIES GOING ON IN EACH ONE
OF THESE 4 AREAS. THE BIG SHIFT IS FRAUD
PREVENTION, AS MUCH AS WE ARE COMMITTED TO
WORKING WITH OUR LAW ENFORCEMENT COLLEAGUES,
EVERYBODY RECOGNIZES YOU CAN'T PROSECUTE YOUR WAY
OUT OF A SITUATION THAT YOU'VE HEARD DESCRIBED
TO YOU TODAY. WE NEED TO DO ALL OF THE
THINGS THAT WE CAN TO PREVENT FRAUD FROM
OCCURRING IN THE FIRST PLACE.
WE ALSO, OF COURSE, NEED TO KEEP DETECTING IT
WHEN IT DOES HAPPEN. WE NEED TO BE OPEN TO
THE PUBLIC, TRANSPARENT AND ACCOUNTABILITY AND,
OF COURSE, WHEN THERE ARE PROBLEMS, WE DO NEED
TO RECOVER THE MONEY THAT WAS WRONGFULLY
SPENT. THIS IS A MAJOR NEW
INITIATIVE. YOU HEARD DESCRIBED
BEFORE THE USES OF DATA IN LAW ENFORCEMENT.
THIS IS AN EXPANSION OF THE ABILITY TO LOOK AT
MULTIPLE SOURCES OF DATA AND INFORMATION, ALL AT
THE SAME TIME. SO NOT JUST LOOKING AT
CLAIMS DATA BUT LOOKING ALSO AT INVESTIGATIONS
BY LAW ENFORCEMENT COLLEAGUES OR PRIVATE
SECTOR FRAUD INVESTIGATORS.
COMPLAINTS, WE HAVE A VERY MUCH ADVANCED
SYSTEM UNDER 1-800-MEDICAID FOR
TAKING COMPLAINTS AND ANALYSTING THE FRAUD
COMPLAINTS THAT COME IN VIA THE 1-800-MEDICARE
SYSTEM. STOLEN IDs, YOU'VE
HEARD A LOT ABOUT THAT. WE HAVE A NEW DATABASE
THAT IS THE COMPROMISED NUMBERS DATABASE THAT
WE'RE USING WHEN WE SUSPECT SOMEONE'S
IDENTITY HAS BEEN COMPROMISED.
WE'RE SCREENING MUCH MORE SYSTEMICALLY AND IN
ADDITIONAL WAYS COMPARED TO THE WAY WE HAD WHEN
PEOPLE WANT TO JOIN THE PROGRAM TO BECOME A
SUPPLIER OR PROVIDER. ALL OF THIS INFORMATION
IS NOW -- WE'RE NOW CAPABLE OF ANALYZING IT
ALL AT THE SAME TIME. AND WE CALL THIS
PREDICTIVE MODELING. BUT WE ARE COMMITTED NOT
JUST TO USING DATA BUT TO GETTING IT RIGHT.
WE SET A GOAL OF MINIMIZING FALSE
POSITIVES OF NOT MAKING LIFE MORE DIFFICULT FOR
HONEST PROVIDERS AND SUPPLIERS, WHILE MAKING
IT REALLY DIFFICULT FOR THE BAD GUYS.
SO THAT'S WHY YOU SEE THAT THIS IS A CYCLE.
AND IT FEEDS BACK ON ITSELF.
WE DEVELOP RISK SCORES, THEN WE TAKE A LOOK AND
SEE WHETHER OUR RISK SCORE TELLS US WHAT WE
THINK IT TELLS US. THAT FEEDS BACK INTO
WHAT WE'RE DOING. ALL OF THIS IS NOW BEING
DEVELOPED. IT'S BEING PARTIALLY
IMPLEMENTED DURING THE COURSE OF THIS YEAR AND
WE WILL BE DOING MORE OVER THE COURSE OF THE
REST OF THIS YEAR AND INTO NEXT YEAR.
I WANT TO POINT OUT IMPORTANT PROVISIONS
UNDER THE AFFORDABLE CARE ACT THAT WILL TAKE
EFFECT. REGULATIONS THAT ENFORCE
THESE WILL TAKE EFFECT NEXT MONTH, MARCH 25.
THESE ARE VERY IMPORTANT NEW TOOLS.
YOU HEARD DESCRIBED FROM LAW ENFORCEMENT THIS
MORNING MUCH ABOUT THE INCREASED PENALTIES THAT
ARE IN THE SENTENCING GUIDELINES.
THERE ARE OTHER PROVISIONS THAT ARE VERY
CENTRAL TO FIGHTING FRAUD, AND THESE ARE 4
OF THEM. WE HAVE NOW ESTABLISH
ADD REGULATORY FRAMEWORK THAT PUTS CATEGORIES OF
PROVIDERS AND SUPPLIERS INTO LIMITED, MODERATE,
AND HIGH RISK. AND ASSIGNING DIFFERENT
KINDS OF SCREENING TO EACH LEVEL SO THAT THE
HIGHEST RISK PEOPLE WILL BE SUBJECTED TO
FINGERPRINTING AND CRIMINAL BACKGROUND
CHECKS AS WELL AS ALL THE OTHER KINDS OF
SCREENING. VERY IMPORTANT NEW
DEVELOPMENTS. THE SECOND BULLET SPEAKS
TO A NEW AUTHORITY IN THE AFFORDABLE CARE ACT
UNDER WHICH THE SECRETARY, IN
CONSULTATION WITH THE INSPECTOR GENERAL, CAN
SUSPEND PAYMENTS PENDING INVESTIGATION OF A
CREDIBLE ALLEGATION OF FRAUD.
WE TAKE THIS VERY SERIOUSLY TO MAKE SURE
THAT AN ALLEGATION IS SUFFICIENTLY CREDIBLE TO
WARRANT SUSPENDING PAYMENTS.
BUT THIS IS A VERY IMPORTANT TOOL THAT WE
WILL BE IMPLEMENTING. AS I SAY THESE TAKE
EFFECT ON MARCH 25. THIRD, THE SECRETARY HAS
A NEW AUTHORITY TO DECLARE A MORATORIUM ON
THE ENROLLMENT OF NEW PROVIDERS, WHEN THERE IS
REASON TO BELIEVE THAT A SUDDEN SURGE, FOR
EXAMPLE, IN NEW PROVIDERS IS NOT RELATED
TO MEETING BENEFICIARY NEEDS BUT MIGHT BE
RELATED TO SOMETHING MORE LIKE FRAUD SCAMS.
AND FINALLY, THERE IS AN IMPORTANT ASPECT OF THE
AFFORDABLE CARE ACT THAT TIES TOGETHER MEDICARE
AND MEDICAID PROGRAM INTEGRITY PROVISIONS.
THIS IS ONE OF THEM. IF SOMEONE IS TERMINATED
FROM A MEDICAID PROGRAM IN ONE STATE UNDER
CIRCUMSTANCES THAT ARE THE KIND THAT WE WOULD
WORRY ABOUT, AND THEY'VE EXHAUSTED ALL THEIR
APPEALS THEY WILL NOW HAVE TO BE TERMINATED
ACROSS THE COUNTRY IN ALL MEDICAID PROGRAMS.
VERY IMPORTANT NEW STEPS.
SO ALL OF THESE ARE IMPORTANT TOOLS THAT WE
HAVE THAT WE'RE PUTTING INTO PLACE.
IT'S A REAL CHANGE IN THE WAY WE'RE GOING
ABOUT OUR BUSINESS. IT'S A VERY IMPORTANT
DEVELOPMENT. AS I SAID WE'RE
IMPLEMENTING THESE WITH GREAT ENERGY AND WITH
ENTHUSIASM. WE'RE ALSO IMPLEMENTING
THEM IN A WAY WE'RE MINDFUL OF THE FACT AND
RESPECTFUL OF THE FACT THAT THE VAST MAJORITY
ARE HONEST PARTNERS IN CARING FOR OUR
BENEFICIARIES. THANK YOU VERY MUCH.
THAT'S MY PRESENTATION. I WILL NOW TURN TO VICKI
NEAL, AND AREA DIRECTOR FOR THE NATIONAL
INSURANCE CRIME BUREAU. THANK YOU.
ON BEHALF OF OUR ORGANIZATION, I
APPRECIATE THE OPPORTUNITY TO ADDRESS
AND BE PART OF THIS PANEL TODAY.
IT'S A VERY IMPORTANT DISCUSSION.
I WOULD LIKE TO VERY BRIEFLY TOUCH ON HOW THE
PROPERTY AND CASUALTY INDUSTRY IS IMPACTED BY
HEALTHCARE FRAUD AND ULTIMATELY ALL OF US.
BEFORE I DO SO, I'D LIKE TO GIVE YOU A LITTLE BIT
OF BACKGROUND ON THE NATIONAL INSURANCE CRIME
BUREAU. WE ARE A NOT FOR PROFIT
ORGANIZATION WITH NEARLY A 100 YEAR HISTORY.
WE'RE SUPPORTED BY MORE THAN 1100 PROPERTY AND
CASUALTY INSURERS ACROSS THE UNITED STATES.
IN ADDITION TO THE INVESTIGATIVE PIECE
WHICH IS ESSENTIAL TO OUR OPERATION, WE ALSO
ARE HEAVILY INVOLVED IN DATA ANALYTICS, THE DATA
TO DATA MINE AND LOOK FOR PROVIDERS THAT ARE
CAUSING THE SYSTEM THE MOST PROBLEMS.
ALSO OUR TRAINING DEPARTMENT.
WE PROVIDE TRAINING TO SPECIAL INVESTIGATIONS
UNITS IN THE PROPERTY AND CASUALTY ARENA AS
WELL AS TRAINING FOR OUR LAW ENFORCEMENT
PARTNERS. WE ALSO WORK TO CHANGE
AND BEEF UP LEGISLATION IN PARTICULAR STATES
WHERE WE'RE SEEING PROBLEMS.
AND MAKE THE PUBLIC MORE AWARE OF HOW INSURANCE
FRAUD EFFECTS US ALL. WE'RE HEAVILY INVOLVED
IN AND HAVE MADE A CONSIDERABLE INVESTMENT
TO AT LEAST ELIMINATE THE BEST WE CAN
HEALTHCARE FRAUD IN THE PROPERTY AND CASUALTY
ARENA. WE FUND 7 MAJOR TASK
FORCES ACROSS THE UNITED STATES IN MORE THAN 35
TASK FORCES, AND THEY CONSIST OF SPECIAL
INVESTIGATIONS UNITS AS WELL AS STATE, LOCAL AND
FEDERAL LAW ENFORCEMENT. LAST YEAR WE WERE VERY
SUCCESSFUL. WE OPENED MORE THAN 1600
CASES. AND WE GENERALLY SAW A
PROSECUTION INCREASE OF ABOUT 4%.
THAT IS EVERYWHERE EXCEPT IN THE STATE OF
MICHIGAN. MICHIGAN IS ESPECIALLY
TROUBLING AND CHALLENGING FOR THE
PROPERTY AND CASUALTY INDUSTRY.
IN THE LAST FEAR YEARS, NICB HAS SEEN A NUMBER
OF OUR QUESTIONABLE CLAIMS REFERRALS SOAR.
IN THE LAST 2 QUARTERS ALONE WE'VE SEEN
QUESTIONABLE CLAIMS SUBMISSIONS REVELS
INVOLVING INSURANCE PROVIDERS BY 108%.
AND IT'S LARGELY BECAUSE MICHIGAN IS SUCH A SOFT
TARGET TO BE PERFECTLY HONEST.
WE'RE THE ONLY PERSONAL INJURY PROTECTION STATE
ANYWHERE IN THE UNITED STATES THAT HAS
UNLIMITED LIFETIME BENEFITS.
AND IF YOU WERE TO FACTOR IN THE WAGE
LOSSES, THE HOUSEHOLD REPLACEMENT SERVICES,
MILEAGE, THERE IS POTENTIAL PAY OFF FOR UP
TO $185,000 THAT CAN BE MADE OFF OF THIS SYSTEM.
AND IN A DEPRESSED ECONOMY I DON'T HAVE TO
TELL YOU HOW ENTICING THAT IS TO SOME PEOPLE
WHO HAVE QUESTIONABLE MOTIVES.
ACCORDING TO III, THE CLAIMS SEVERITY IN THIS
STATE IS ABOUT $34,000. AND THAT IS TWICE THE
AMOUNT OF THE SECOND HIGHEST STATE WHICH IS
NEW JERSEY. IN THIS CASE IT COST A
SUPPORT AND CASUALTY INSURER 57% MORE TO
SETTLE A PERSONAL PROTECTION CLAIM THAN
ANYWHERE ELSE IN ANY LIKE STATE.
WE ESTIMATE -- THERE IS SOME INDUSTRY EXPERTS
THAT ESTIMATE THE BUILDUP BETWEEN 4.2 AND
$6.8 BILLION ANNUALLY. AND THAT'S ALL DESPITE
THE FACT THAT THE NHTSA ACTUALLY SAYS THAT THE
FREQUENCY AND VERTCY OF AUTO ACCIDENTS HAS
DECREASED IN MICHIGAN. THE MAJORITY OF
HEALTHCARE PROVIDERS IN THIS STATE ARE HONEST,
HARD WORKING INDIVIDUALS WHO ARE THERE AND
COMMITTED TO PROPER MEDICAL CARE.
AND PROVIDING SUPERIOR CARE TO THEIR PATIENTS.
BUT WE CAN'T AND WE'RE NOT IGNORING THE FACT
THAT THERE ARE OTHERS WHO ARE NOT.
RECENTLY, THE FDI AND NITB TOOK A LOOK AT OUR
CASES ON THE PRIVATE SIDE VERSES FEDERAL
CASES ON THE FEDERAL SIDE.
WE FOUND SIGNIFICANT CROSS OVER AS YOU HEARD
REPEATEDLY. WE'RE LOOKING AT MUCH
THE SAME PEOPLE. SOMETIMES WE'RE
RELUCTANT TO SHARE INFORMATION AND TALK TO
EACH OTHER. MORE IMPORTANTLY, SHARE
RESOURCES. WE SEE THE SAME PATTERNS
THAT YOU'VE HEARD ECHOED BY OTHER PANELISTS.
WE'VE SEEN THE MIGRATION OF MEDICAL PROVIDERS
THAT ARE FORCED OUT OF OTHER STATES,
PARTICULARLY FLORIDA, PARTICULARLY NEW JERSEY.
WE HAVE DOCTORS COMING HERE FROM CONNECTICUT TO
TAKE ADVANTAGE OF THIS UNLIMITED LIFETIME
BENEFIT PACKAGE. LIKE MANY OTHER SPEAKERS
AS WAS NOTED THE SYSTEM THAT WE SEE IS DEPENDENT
ON RUNNERS AND CAPPERS, OR RECRUITERS AS THEY'RE
ALSO CALLED. WE SEE THEM, THEY ARE
PAID PER PATIENT. THE EMPHASIS IS TO BRING
IN AS MANY PATIENTS AS POSSIBLE.
THEY WILL BRING THEM INTO A STRUCTURE, AN
ORGANIZATION THAT WE COMMONLY REFER TO AS A
DOCK IN THE BOX, THE CORPORATE PRACTICE OF
MEDICINE. PROVIDERS COME IN FROM
EVERY ARENA AND MAKE CONTINUAL REFERRALS.
THEY RECRUIT FROM THE HOMELESS SHELTERS, PICK
UP ADDICTS, THEY WILL PERSONALLY DIFFER THEM
TO AN INSURANCE AGENT AND PURCHASE A POLICY IN
THEIR NAME. AND QUITE OFTEN THEY'LL
SIGN THEM UP WITH A CORRUPT ATTORNEY BEFORE
THEY EVER STEP FOOT IN THE MEDICAL CLINIC.
THE GOAL HERE IS IT'S NOT GOOD PATIENT CARE.
THE GOAL IS ABOUT MAXIMIZING BILLING.
THEY WILL BE AROUND A PHYSICAL THERAPY, AS
WELL AS CHIROPRACTIC TREATMENTS, AND OFTEN
IT'S A STEADY STREAM OF NARCOTICS THAT FUELS THE
EPIDEMIC PRESCRIPTION DRUG ABUSE.
THEN THERE ARE REFERRALS TO OTHER DOCTORS FOR THE
BATTERY OF TESTS. THE POPULAR CHOICE FOR
THE PROPERTY AND CASUALTY IS $30,000
PROCEDURE KNOWN AS MANIPULATION UNDER
ANESTHESIA. IT'S NOTHING MORE THAN
THAT MAKING A CHIROPRACTIC ADJUSTMENT
WITH THE PATIENT UNDER ANESTHESIA.
MOST HEALTHCARE EXPERTS THROUGHOUT THE UNITED
STATES WILL TELL YOU THIS PROCEDURE IS NOT
ONLY UNNECESSARY, IT'S HIGHLY DANGEROUS TO THE
PATIENT. I THINK PERHAPS ONE OF
THE MORE POIGNANT EXAMPLES WITHOUT GOING
INTO SPECIFIC CASES THAT WE'RE INVESTIGATING, ONE
OF THE MOST POIGNANT ILLUSTRATIONS IS THE
LACK OF SOUND MEDICAL CARE, IS THAT OF A
92-YEAR OLD WOMAN HERE IN MICHIGAN WHO HAD A
PACE MAKER. SHE WENT INTO A
CHIROPRACTIC FACILITY FOR TREATMENT.
SHE WAS HAVING PROBLEMS WITH HER BACK.
AND YOU HAD AN UNLICENSED RECEPTIONIST
HOOKING HER UP FOR ELECTRIC STIMULATION.
NEEDLESS TO SAY, HER CARDIOLOGIST WAS NOT
AMUSED AT ALL. SO WE'RE NOT TALKING
ABOUT JUST NECESSARILY UNNECESSARY MEDICAL
PROCEDURES. WE'RE TALKING ABOUT
DANGEROUS MEDICAL PROCEDURES.
AND IT'S NOTHING MORE THAN A KICKBACK SCHEME.
IF THE RUNNERS AND CAPPERS CAN TARGET
SOMEONE WHO ALSO HAS THE RED, WHITE AND BLUE CARD
THE PAY OFF IS EVEN GREATER.
UNFORTUNATELY, LAW ENFORCEMENT DOES NOT
HAVE THE RESOURCES TO ADEQUATELY ADDRESS THE
PROBLEM. PROSECUTORS TRY AS THEY
MIGHT ARE FACING ENORMOUS CASE LOADS THAT
INVOLVE VIOLENT CRIMES THAT TAKE UP ALL THEIR
TIME AND RESOURCES. I CAN TELL YOU AS THE
AREA DIRECTOR OF NITB FOR THIS AREA AS WELL 5
OTHER STATES, THAT I CAN COUNT ON ONE HAND THE
NUMBER OF HEALTHCARE PROVIDER WHOSE ARE
ENGAGED IN A DOCK IN THE BOX SCHEME TARGETING THE
PROPERTY AND CASUALTY INDUSTRY WHO HAVE BEEN
PROSECUTED IN THE LAST 5 YEARS.
MANY PEOPLE SAY SO WHAT? IT'S INSURANCE FRAUD.
THERE IS INSURANCE COMPANIES, THEY HAVE
DEEP POCKETS. MORE THAN $30 BILLION IS
ATTRIBUTED TO INSURANCE FRAUD IN THE UNITED
STATES. AND THAT COST IS
ABSORBED BY HONEST CONSUMERS IN THE FORM OF
HIGHER INSURANCE PREMIUMS.
AND I CAN ASSURE YOU THAT AS OUR FEDERAL
GOVERNMENT LAW ENFORCEMENT PARTNERSHIPS
ARE MORE EFFECTIVE IN EXCLUDING PROVIDERS FROM
THE SYSTEM, MANY OF THESE CORRUPT MEDICAL
PROVIDERS PARK THEMSELVES AT THE DOOR
OF THE PROPERTY AND CASUALTY INDUSTRY.
VIRTUALLY MAKING INSURANCE UNAFFORDABLE
IN THIS STATE. THIS CONFERENCE OFFERS
US SOME UNIQUE OPPORTUNITIES FOR
DISCUSSION. WE HAVE A CHANCE TO
UTILIZE OUR COMBINED TALENTS, OUR
INVESTIGATOR RESOURCES, OUR DATA ANALYTICS.
TO TALK FOR THE FIRST TIME ABOUT HOW WE CAN
EFFECTIVELY ADDRESS HEALTHCARE FRAUD.
NICB IS ABSOLUTELY COMMITTED TO BEING PART
OF THAT SOLUTION. OUR ORGANIZATION
STRONGLY SUPPORTS THE FORMATION OF A STATE
FRAUD BUREAU. TOUGHER RUNNERS AND
CAPPER STATUTES, AS WELL AS THE COMMON SENSE FEE
SCHEDULE THAT'S FAIR TO EVERY ONE.
WE ALSO SUPPORT A FEDERAL IMMUNITY STATUTE
THAT PERMITS US AS AN INVESTIGATIVE TOOL TO
SHARE INFORMATION THAT'S CRITICAL TO OUR SUCCESS.
ONCE AGAIN, I THANK YOU FOR THE VOLUNTEER TO
TELL YOU ABOUT WHAT WE DO AT NICB AND HOW WE
PARTNER WITH THE INSURANCE INDUSTRY.
I HOPE THIS IS AN OPPORTUNITY TO OPEN UP
FURTHER DISCUSSIONS ABOUT HEALTHCARE FRAUD
AND WHAT WE CAN DO TO PREVENT IT.
THANK YOU. [APPLAUSE]
THANK YOU VERY MUCH. I THINK THAT IS A REAL
EYE OPENER FOR MANY PEOPLE TO UNDERSTAND
THAT HEALTHCARE FRAUD EFFECTS NOT ONLY
MEDICARE, MEDICAID AND PRIVATE HEALTH INSURANCE
COMPANIES BUT ALSO EFFECTS OUR PROPERTY AND
CASUALTY INSURANCE COMPANIES AS WELL.
OUR NEXT SPEAKER, DR. MARTHA POLLOCK,
CORPORATE MEDICAL DIRECTOR FROM INTEGRATED
HEALTH SERVICES AT BEAUMONT HOSPITALS.
THANK YOU FOR THE OPPORTUNITY TO SPEAK
TODAY. I'M A PRACTICING PRIMARY
CARE PHYSICIAN HERE IN THE DETROIT AREA, HAVE
BEEN FOR ABOUT 20 YEARS. IT WAS WITH GREAT
INTEREST AND AMAZEMENT THAT I READ MY
NEWSPAPERS OVER THE WEEKEND AND LISTENED TO
THE FRISK PANEL AT THE CONFERENCE TO TALK ABOUT
THE RATHER LARGE SCALE SCAMS AND CRIMINAL
ACTIVITY GOING ON RIGHT IN MY OWN NEIGHBORHOOD.
I'M HERE TODAY ACTUALLY TO TALK FROM A DIFFERENT
PERSPECTIVE. I WANT TO TALK ABOUT THE
CHALLENGES FACING THE LEGITIMATE PROVIDER IN
PREVENTING HEALTHCARE FRAUD.
I WONDER IF ANYONE WOULD BE SURPRISED IF I TOLD
YOU THAT I'M ASKED TO COMMIT HEALTHCARE FRAUD
ON AN ALMOST DAILY BASIS.
I HAVE PATIENTS WHO WILL ASK ME TO ORDER DURABLE
MEDICAL EQUIPMENT THAT THEY REALLY DON'T NEED.
THEY MAY BE ASKED FOR THE HOSPITAL BED.
THEY WANT THE MOTORIZED WHEELCHAIR.
THEY WANT ME TO CERTIFY THAT THEY NEED HOME
HEALTHCARE WHEN THEY'RE NOT HOME BOUNDS.
THEY ASK ME TO KEEP THE FAMILY MEMBER IN A
HOSPITAL AN EXTRA DAY OR 2 SO THEY CAN QUALIFY
FOR THE NURSING HOME BENEFIT.
THEY WILL OCCASIONALLY DROP A FAMILY MEMBER OFF
ON A THURSDAY OR FRIDAY NIGHT SO THE FAMILY CAN
GO OUT OF TOWN FOR THE WEEKEND AND EXPECT THAT
I AM AND THE HOSPITAL WILL BILL MEDICARE FOR
THAT SERVICE. THEY ASK FOR OUTPATIENT
PROCEDURES TO BE SCHEDULED AS AN
INPATIENT SO THEY DON'T INCUR THE OUT OF POCKET.
COPAYS ON OCCASION. NOW, THESE PEOPLE ARE
NOT CRIMINALS. THEY ARE NOT TRYING TO
RUN A SCAM. THEY'RE NOT TRYING TO
BILK THE SYSTEM. AS A PROVIDER, WHEN I
TRY TO EXPLAIN TO THEM THAT THIS IS FRAUD, I
CAN'T DO THAT, WHAT I GET IS AN ANGRY
CONSUMER. I GET A DISGRUNTLED
PATIENT. AND MOST PROVIDERS WILL
TELL YOU THAT THE DISGRUNTLED PATIENT, THE
ANGRY CUSTOMER, IS THE ONE WHO IS MORE LIKELY
TO BE LITIGIOUS, LIKELY TO FILE A COMPLAINT CAN
CMS, WITH JAKO AND MANY PROVIDERS WILL TAKE THE
PATH OF LAST RESORT AND AT TIMES TRY TO PACIFY
THIS INDIVIDUAL. AGAIN, THIS INDIVIDUAL
IS NOT TRYING TO COMMIT A CRIME.
THEY HAVE NO IDEA THAT WHAT THEY'RE ASKING FOR
IS PERHAPS NOT APPROPRIATE OR COULD BE
CONSIDERED FRAUDULENT ACTIVITY.
WHAT THEY WILL DO IS THEY'LL LOOK AT ME AND
SAY YOU KNOW WHAT? IF YOU WON'T DO IT I'LL
FIND SOMEONE WHO WILL. THIS IS THE INDIVIDUAL
WHO WILL, THEN, FALL PREY TO SOME OF THESE
LARGER SCAMS THAT WE SEE GOING ON.
I WAS VERY INTERESTED TO HEAR THE BENEFICIARY
PANEL EARLIER TODAY TALK ABOUT GETTING A SAVVY
CONSUMER. AND I THINK CERTAINLY
THE BEST DEFENSE IS A GOOD OFFENSE.
IF WE HAVE SAVVY CONSUMERS, IF WE HAVE
THE AREA AGING REPRESENTATIVE WHOSE ARE
OUT THERE HELPING US EDUCATE OUR CUSTOMERS,
EDUCATE OUR PATIENTS ABOUT WHAT IS AND IS NOT
A COVERED BENEFIT. WHAT IS AND IS NOT
APPROPRIATE CARE, THIS IS THE BEST WAY TO AVOID
LOSING PATIENTS TO THE SCAMMERS.
AND THE SAVVY CUSTOMER IS MY BEST HOPE AS A
LEGITIMATE PROVIDER TO BE ABLE TO COMPETE WITH
THE CROOKS. SO THAT'S REALLY ALL I
HAD TO SAY TODAY. I WANT TO THANK YOU FOR
THE OPPORTUNITY TO SPEAK.
[APPLAUSE]. THANK YOU VERY MUCH.
I THINK THAT NICELY PORTRAYS THE CHALLENGE
WE ALL FACE IN TERMS OF EDUCATING OUR
BENEFICIARIES, OUR PATIENTS, ALL OF US MUST
BE AWARE OF WHAT THE ISSUES ARE.
DR. VILLARIN, THE NATIONAL DIRECTOR OF
PHYSICIAN SERVICES FOR THOMSON REUTERS.
MAY I HAVE THE CLICKER PLEASE?
YES, YOU MAY. GOOD MORNING.
I'M DR. ALBERT VILLARIN, EMERGENCY PHYSICIAN AND
NATIONAL DIRECTOR FOR PHYSICIAN SERVICES FOR
THOMSON REUTERS HEALTHCARE U.S.
THOMSON REUTERS HAS BEEN ENGAGED TO ENSURE
PRESUME INTEGRITY FOR MANY DECADES.
ONE, HOW WE VIEW THE PROBLEMS OF WASTE AND
FIGHT FRAUD, LOOK HOW WE'RE EFFECTIVELY
MEASURING AND DECREASING THE WASTE OF FRAUD THAT
OCCURS AND TAKE SUCCESSFUL ACTION
AGAINST CASES AND TO ASSURE THE INVESTIGATION
OF NOT ONLY STATISTICALLY INCORRECT
INFORMATION BUT ALSO CLINICALLY CORRECT
INFORMATION AND ACCURATELY DIAGNOSE
THOSE. THE CONTINUUM.
OUR SPECIALTY IS MEASURING COST AND
QUALITY IN HEALTHCARE, INFORMING STAKEHOLDERS
IN THE SYSTEM TO BETTER MANAGE CARE.
WE SEE ALL CAREGIVERS BY PROVIDERS FROM MEDICAL
TRANSPORTATION, TO HOME HEALTHCARE, TO PHYSICIAN
PRACTICES, TO HOSPITALS. ALL FALLING ON A
CONTINUUM OF CRIMINAL BEHAVIOR TO COMMENDABLE
BEST PRACTICE. WE RECOGNIZE THE VAST
MAJORITY OF PROVIDERS FALL AT OR NEAR THE
COMMENDABLE BEHAVIOR END OF THE CONTINUUM.
EACH BEHAVIOR DEMANDS DIFFERENT INTERVENTION
FROM PROSECUTION OF INDIVIDUALS COMMITTING
FRAUD, TO DEMANDING REPAYMENT, TO EDUCATION
OF INDIVIDUALS WITH WEIGHTFUL PRACTICES TO
REWARDING INDIVIDUALS WHO ARE PERFORMING AT
THE PEEK OF THEIR PRACTICE.
THERE HAVE BEEN 2 PAPERS WRITTEN THE U.S.
HEALTHCARE. THE FIRST IS WHERE CAN
$700 BILLION IN WASTE BE CUT ANNUALLY FROM THE
U.S. HEALTHCARE SYSTEM? AND THE OTHER IS A PATH
TO ELIMINATING $3.6 TRILLION WASTEFUL
DOLLARS OF HEALTHCARE SPENDING.
EACH BRINGS TOGETHER WORKS, ESTIMATING THE
SIZE OF THE PROBLEM OF THE U.S. HEALTHCARE
SYSTEM AND OFFER STRATEGIES TO ELIMINATE
SUCH WASTE IN THE HEALTHCARE SYSTEM AND
PREVENT FRAUD AND ABUSE. THE $700 BILLION OF
WASTE IS BROKEN DOWN INTO 6 SPECIFIC
CATEGORIES INCLUDING FRAUD AND WASTE.
FRAUD AND ABUSE. OUR RESEARCH SHOWS THAT
FRAUD AND ABUSE AMOUNTS TO 19% OF THE PROBLEM OR
125 TO $175 BILLION ANNUALLY.
BASED ON OUR EXPERIENCE, WE KNOW THAT A WHOLE
SYSTEM OF CHECKS PANNED BALANCES GOES INTO
PROGRAM INTEGRITY. TODAY WE'LL FOCUS ON
WHERE THE MOST IMPACT FIGHTING FRAUD CAN BE
ACHIEVED THROUGH BETTER CREDENTIALING, MORE
EFFECTIVE PREVENTION AND CONTINUING TO INCREASE
ANALYTIC AND INVESTIGATION.
MORE CAN BE DONE IN THE AREA OF PROVIDING
CREDENTIALING BEFORE ALLOWING PROVIDERS TO
BILL FOR SERVICES. BACKGROUND CHECKS
INCLUDING CHECKING NATIONAL DATABASES, TO
SHOW WHETHER A PROVIDER HAS A SANCTION IN ANY OF
THE 50 STATE MEDICAID AGENCIES OR THE HHS OIG
AS WELL AS CRIMINAL HISTORY AND OTHER RISK
FACTORS COULD HELP PREVENT FRAUD FROM
HAPPENING IN THE FIRST PLACE.
MORE EFFECTIVE PREVENTION CAN ACHIEVE
USING EDIT TO REFLECT FEDERAL, STATE, PLAYERS
POLICY AND EVIDENCE BASED STANDARDS.
PRACTICE OF MEDICINE SUCH A NATIONAL CORRECT
CODING INITIATIVE, ALL OF THIS BEFORE A CLAIM
IS EVER PAID. THERE ARE BLACK AND
WHITE RULES. A DIALOGUE THAT PROVIDES
PROVIDERS TO UNDERSTAND PAYMENT RULES AS THEY
CHANGE. MORE CAN BE DONE TO
SUPPORT INVESTIGATORS, ANALYTICS ARE PROVIDING
RETURNS ON INVESTMENT BETWEEN 3-$12 FOR EVERY
DOLLAR SPENT. SOME OF THE TECHNOLOGIES
WE USE AT THOMSON REUTERS.
PHYSICIANS ARE SCIENTISTS AND WE LIKE
DATA AND ANALYTICS. WE WANT TO ENSURE THAT
THINGS ARE NOT ONLY STATICALLY CORRECT, BUT
ALSO CLINICALLY CORRECT AND EVIDENCE BASED.
WE LOOK AT TECHNOLOGIES LIKE PREDICTIVE
ANALYTICS, COMBINING STATISTICAL TECHNIQUE
AND EXPERTISE
TO PREVENT FRAUD.
AS WE IDENTIFY HIGH RISK PROVIDERS AND
BENEFICIARIENED AND BEHAVIORS, WE LOOK AT
MORE COMPLEX ANALYSTS UTILIZING ALGORITHM TO
PREDACIOUS DASH BOARD. THEY INFORM
INVESTIGATORS. EFFECT WENT AND CORRECT
[INAUDIBLE] COLLEGE ALL THIS!
FOR SIX PROVIDERS. FURTHER, TO ***
DETERMINE IS A CLAIM IS CORRECTION, WE USE TOOLS
THAT GROUP CARE INTO 550 DISEASE CATEGORIES AND
VARIOUS STAGES. EPISODE GROUPING,
ENABLES INVESTIGATORS TO LOOK AT CLAIMS TO
DETERMINE IF THEY ARE APPROPRIATE OR
CLINICALLY CORRECT. IF THEY CAN'T BE MATCHED
TO A STANDARD OF PRACTICE OF CARE.
FINALLY IT'S IMPORTANT TO UTILIZE PUBLIC RECORD
DATA, IDENTIFYING PROVIDERS WITH SANCTIONS
WITHIN THE 50 STATES. CLINICAL HISTORY AND
BUSINESS RELATIONSHIPS BETWEEN SUSPICIOUS
PROVIDERS ALSO PROVIDE KEEN INSIGHT TO
INVESTIGATORS. THESE ARE SOME OF THE
EXAMPLES OF TECHNOLOGIES WE USE TO ENSURE
ACTIVITY IS CORRECT, IDENTIFIES THE WASTE AND
FRAUD WITHIN THESE CATEGORIES.
SOME CLINICAL EXAMPLES WE'LL DISCUSS HERE
MOMENTARILY. SOME OF WHAT WE LOOK AT
IS WHETHER THERE IS A REASONABLE PRACTICE
STANDARD IN TERMS OF TIME SPENT WITH
PATIENTS. WE LOOKED AT
PSYCHIATRISTS WHO HAD MORE THAN 12 HOURS OF
PATIENT FACE TIME IN A SINGLE DAY.
WE TAKE THE CMS TIME STANDARD FILE AND
APPLIED IT AGAINST THE PROCEDURES TO UNDERSTAND
WHERE THERE IS A PRACTICE PATTERN
SUSTAINED OVER TIME THAT EXCEEDS ANY REASONABLE
AMOUNT OF CARE FOR THAT PROVIDER TYPE.
THIS CAN BE DONE FOR ANY PROVIDER TYPE, CONTROLS
ALSO PUT IN PLACE TO ALLOWS FOR SPECIALISTS
AND BEST PRACTICED PROVIDERS, WE IDENTIFY
SPECIFIC PROVIDERS. WE HAVE FOUND PROVIDERS
PRACTICING 24 HOURS A DAY 7 DAYS A WEEK, 365
DAYS A YEAR. WELL OUTSIDE THE
REASONABLE PRACTICE STANDARD.
THIS PARTICULAR SCHEME WAS AMPLIFIED WHEN WE
COMBINED MEDICAID AND MEDICARE CLAIMS, FLYING
UNDER THE RADAR IN EITHER PROGRAMS.
WHEN COMBINED THEY ARE PRACTICING AT AN
UNREASONABLE STANDARD. ON THIS SLIDE WE LOOK AT
CASES OF BENEFICIARIES RECEIVING PLIES.
THERE IS NO DIAGNOSIS. THERE ARE CROSS CLAIMS
ANALYSIS SO YOU'RE NOT JUST LOOKING AT ONE TYPE
OF CLAIM. YOU'RE BRINGING ALL THE
INFORMATION TOGETHER IN ONE PLACE TO COMPARE IT
TO CROSS CLAIM TYPES. WE LOOK AT OTHER TESTS
AS WELL. LAB ACTIVITY.
STANDARDS OF CARE AND GROUPS OF TECHNOLOGY.
IN THIS CASE THE LAB SERVICES FOR PEOPLE WHO
HAD NO RELATED EPISODE OF CARE OR PHYSICIAN
OVERSIGHT. WE IDENTIFIED LAB TESTS
THAT COULD BE GROUPED WITH SPECIFIC DIAGNOSES.
TESTS WERE ADDED TO A LAB PANEL BILLED OUTSIDE
THE STANDARD PRACTICE OF CARE.
THE ANALYSIS REVEALED BENEFICIARY ID NUMBERS
BEING PURCHASED FOR FRAUDULENT BILLING,
RESULTING IN SIGNIFICANT RECOVERIES.
ALGORITHM CAN DETERMINE DRUGS WHERE DRUGS ARE
INAPPROPRIATE. IN THIS CASE
INAPPROPRIATELY SCRIPTS. THESE WERE ASSOCIATED
WITH QUESTIONABLE MEDICAL NECESSITY,
REFERRED FOR BILLING REVIEW.
DRILL DOWN REPORTING IN THIS CASE AND IDENTIFIES
COLLUSION FOR THE PHARMACY AND LED TO
INDICTMENTS. ALL THESE ARE
APPLICATIONS OF ANALYTIC TOOLS.
WE MAY NOT ALWAYS IDENTIFY FRAUD BUT IN
MANY INDICATIONS WE'RE IDENTIFYING PROVIDERS
THAT NEED COACHING OR EDUCATION TO PROVE THEIR
BILLING OR PRACTICES TO COME INTO COMPLIANCE
WITH NATIONAL STANDARDS AND LOCAL POLICY.
ON THIS SLIDE WE RECOGNIZE THE ULTIMATE
GOAL TO REINFORCE IMPROVEMENT AND AOPTION
OF BEST PRACTICES. IS THERE IS A VAST
MAJORITY OF PROVIDERS OUT THERE THAT PRACTICE
GREAT MEDICINE. THEY ARE PRACTICING
WITHIN GUIDELINES. WE RECOGNIZE THE SYSTEM
THAT IDENTIFIES THE OUTLIERS AT THE BOTTOM
OF THE SPECTRUM ALSO NEEDS TO LOOK AT THE TOP
PERFORMERS TO IMPROVE EFFICIENCIES, WE LOOK AT
COLD GUARD PROGRAMS, TO PROVIDE NO RISK
PROVIDERS. FINALLY, 3 SPECIFIC TAKE
AWAYS. FIRST, DO NOT HARM, AS A
PHYSICIAN. TO ASSURE ALL SOLUTIONS
ARE IMPLEMENTED, PROVEN, AND NOT ONLY
STATISTICALLY ACCURATE, BUT CLINICALLY
INTELLIGENT. REMEMBER THAT THE
MAJORITY OF PROVIDERS ARE THE GOOD GUYS.
DON'T WASTE TIME. USE SMART SYSTEMS OF
TECHNOLOGY. HAVE PREVENTION AND
FEEDBACK SYSTEMS. UTILIZE A NETWORK OF
EXPERTS. THIS IS ABOUT IMPROVING
OUR HEALTHCARE SYSTEM. THANK YOU.
[APPLAUSE] THANK YOU VERY MUCH.
IN ADDITION TO PSYCHIATRISTS THAT
PRACTICE 24 HOURS A DAY, I'M PARTICULARLY
INTRIGUED BY PHYSICIANS WHO WERE ABLE TO SEE
PATIENTS IN 2 CITIES A COUPLE OF THOUSAND MILES
APART ON THE SAME DAY. OUR LAST PANELIST,
CYNTHIA WISNER. ASSOCIATE COUNSELOR FOR
TRINITY HEALTH. THANK YOU.
I WANTED TO APPRECIATE ALL OF YOU FOR COMING
TOGETHER AND ALSO EXPRESS YOUR AND OUR
APPRECIATION FOR THE OPENNESS OF THE
GOVERNMENT AGENCIES, THE REGULATORS, AND THE LAW
ENFORCEMENT AGENCIES TO EXPRESS THAT THEY
RECOGNIZE THERE ARE LEGITIMATE PROVIDERS OUT
HERE. AND THAT WE ARE
CHALLENGED BY THE SAME ENVIRONMENT THAT IS
CHALLENGING THEM. THE ILLEGITIMATE
PROVIDERS ARE GIVING US A BAD NAME.
WE APPRECIATE THE CLEAR OUR NAME THROUGH THIS
TYPE OF COLLABORATION AND THIS OPENNESS TO
LEARNING ABOUT THE PRACTICE OF MEDICINE,
THE DELIVER OF HEALTHCARE.
I AM HERE TODAY BECAUSE OUR ORGANIZATION HAS A
SHARED GOAL OF HIGH QUALITY AFFORDABLE
HEALTHCARE WITH ACCESS, NOT ONLY FOR THE
MEDICARE POPULATIONS BUT FOR THE ENTIRE
POPULATIONS. I HAD TO SPOOF MY
GOVERNMENT FRIENDS AND COLLEAGUES WITH A
DISCLAIMER AS A INHOUSE COUNSEL AT A PROVIDER
ORGANIZATION, I NEED TO NOTE THAT MY COMMENTS
ARE BASED ON 30 PLUS YEARS EXPERIENCE IN
VARIOUS SETTINGS AND THEY ARE NOT THE
OFFICIAL POSITIONS OF MY EMPLOYER AND I'M UNABLE
TO BIND MY EMPLOYER TODAY WITH MY COMMENTS.
[LAUGHTER] A FEW FAST FACTS THAT
YOU CAN FIND OUT ABOUT TRINITY HEALTH.
VERY PROUD TO BE AN EMPLOYEE AND ASSOCIATE
OF TRINITY HEALTH FOR OVER TEN YEARS.
YOU CAN FIND OUT MORE ABOUT US ON OUR WEBSITE.
WE'RE VERY PLEASED TO BE IN THE DISCOVERY OF
HEALTHCARE AS A CATHOLIC HEALTHCARE PROVIDER.
WE'RE THE 4th LARGEST CATHOLIC HEALTHCARE
PROVIDER IN THE UNITED STATES.
WE HAVE A CHALLENGING NUMBER OF EMPLOYEES
INDEPENDENT AND EMPLOYED MEDICAL STAFF MEMBERS,
INCLUDING PHYSICIANS. WE ORGANIZE INTO 19
MINISTRY ORGANIZATIONS, 46 HOSPITALS, AND WE
HAVE THE VARIETY OF CLINICS THAT WE HAVE
HEARD ABOUT TODAY WITH OUTPATIENT CLINICS, LONG
TERM CARE FACILITIES, HOME HEALTH, ET CETERA.
MOST IMPORTANTLY ONE OF THE THINGS WE CONTRIBUTE
TO THE DELIVERY OF HEALTHCARE IS THE
COMMUNITY BENEFIT MINISTRY WE HAVE.
OUR PROFITS ARE PUT BACK INTO SERVICES FOR THE
COMMUNITY. AND OUR GOAL IS TO SERVE
THE COMMUNITY AND PROVIDE ACCESS.
THAT IS CHALLENGING IN THIS COMPLICATED ARENA
WHERE THE FUNDING IS GOVERNORENED BY MULTIPLE
RULES OF MULTIPLE AGENCIES.
SO JUST A -- WANTED TO BRING EVERY ONE'S
ATTENTION THAT THE FUNDS NOT ONLY FUND THE DIRECT
CARE OF HEALTHCARE BUT THEY ALSO FUND OTHER
ACTIVITIES OF HEALTHCARE LEGITIMATE HEALTHCARE
PROVIDERS. ONE OF THE THINGS THAT
MAKES US SUCCESSFUL IS OUR COMPLIANCE PLAN.
WE HAVE HAD A COMPLIANCE PLAN IN EFFECT FOR THE
PAST 13, 14 YEARS. WE ADOPTED IT IN 1997.
AND WE'RE COMMITTED TO ACTING WITH INTEGRITY
AND MAKING DECISIONS BASED ON THE HIGHEST
STANDARD OF ETHICAL BEHAVIOR.
THAT MEANS THAT OUR GOAL IS TO BILL AND TO
PROVIDE CARE IN A COMPLIANT MANNER.
WE SHARE DR. POLLACK'S DILEMMA OF MEETING THE
NEEDS OF OUR BENEFICIARIES AND
COMPLYING WITH THE RULES FOR BILLING AND
PROVISION OF CARE. WHAT'S BEEN THE VALUE TO
US OF OUR INTEGRITY PLAN, IT'S VERY VALUABLE
IN ENSURING THE INTEGRITY OF OUR
REVENUE. IT FOSTERS A DO THE
RIGHT THING CULTURE, DO IT RIGHT, DO IT
CORRECTLY, CODE IT CORRECTLY.
DON'T CODE AS WE HEARD ONE OF THE PANELISTS
THIS MORNING, ONE OF THE DIABETIC
TREATMENTS BEING IMPROPERLY CODED TO GET
A HIGHER REIMBURSEMENT RATE.
IT'S ENCOURAGES SELF-REPORTING.
THOSE THAT BELIEVE WE'RE MAKING AN ERROR OR
COMPROMISINGS OUR VALUES HAVE THE OPPORTUNITY TO
SELF-REPORT. IT'S ALSO EFFECTIVE
BECAUSE WE HAVE BUDGETED FUNDING FOR OUR
COMPLIANCE PLAN AND WE HAVE A DIRECT REPORT TO
GOVERNORS, TO THE PRESIDENT AND OUR BOARD
OF DIRECTORS AND THEY ARE ACTIVELY COMMITTED
AND SUPPORTIVE OF OUR COMPLIANCE PLAN.
THIS IS A BIT OF A BUSY SLIDE.
I THOUGHT IT WOULD BE A GOOD VISUAL ILLUSTRATION
OF THE CHALLENGES THAT LEGITIMATE PROVIDERS
FACE. AND THAT IS THAT THE
MONEY ONLY GOES SO FAR. OUR MEDICAID, MEDICARE
AND INSURANCE HAS TO COVER NOT ONLY THE
DELIVERY OF CARE BUT OBVIOUSLY THE INVESTMENT
WE'RE MAKING IN COMPLIANCE AND
INTEGRITY. AND TO DO THAT, WE HEARD
THAT THERE ARE CHANGING RULES AND WE ALL KNOW.
THAT REQUIRES OUR INVESTMENT INCLUDE
TRAINING AND EDUCATION. WE DO INTERNAL AUDITS,
AND BENCHMARKING OF THE TYPE YOU HEARD ABOUT AND
SOME OF THE TOOLS THAT ARE AVAILABLE OUT THERE
WE USE IN ORDER TO DO BENCHMARKING.
WE ALSO HAVE A HOT LINE FOR THOSE WITH CONCERNS
AND WE FOLLOW UP AND INVESTIGATE THOSE
COMPLAINTS. WE DO PAYMENT DENIAL
FOLLOW UP TO DETERMINE WHETHER WE HAD AN ERROR,
PERHAPS IN A SOFTWARE PROGRAMMING.
AND THEN WE FOLLOW UP WITH MODIFICATIONS TO
THOSE TYPES OF ERRORS THAT OCCUR WHEN WE HAVE
BAD MAPPING OR WE HAVE NOT YET CAUGHT UP IN
CHANGES IN FUNDING AND REIMBURSEMENT.
SOME OF THE EXPENSES THAT WE'RE CHALLENGED
WITH IS -- IN ADDITION TO OUR INVESTMENT AND
INTEGRITY PLAN INCLUDES THE DUPLICATE MEDICAL
RECORD PRODUCTION. IN ONE INSTANCE WE HAVE
BEEN ASKED TO PRODUCE THE RECORD WITH THE
LEGITIMATE OBLIGATION OF THE ORGANIZATION TO
PRODUCE IT, AND THE LEGITIMATE RIGHT OF THE
AGENCIES TO SEE IT, BUT TO 3 OR MORE DIFFERENT
AGENCIES AND ORGANIZATIONS ENGAGED TO
DO COMPLIANCE. ONCE WE DEFEND THE
RECORD, AND PERHAPS TAKE IT THROUGH AND ALJ
HEARING, AND DETERMINED TO HAVE PROVIDED PROPER
CARE, SOMETIMES THAT RECORD CAN BE CHALLENGED
AGAIN OR THE SAME PRACTICE CAN BE
CHALLENGED AGAIN AS PART OF THE GOVERNMENT
INVESTIGATION. THE COST OF E DISCOVERY
ARE TREMENDOUS, DESPITE THE COMMITMENT TO
MEDICAL RECORDS, ELECTRONIC MEDICAL
RECORDS WE STILL HAVE PAPER.
ALL PROVIDERS STILL HAVE PAPER.
AND IT'S NOT AN EASY LABOR NON INTENSE METHOD
OF FINDING DOCUMENTS IN CONNECTION WITH THE
DOCUMENT REQUEST. SO THOSE -- THE
GOVERNMENT'S COMMITMENT TO WORKING
COLLABORATIVELY WITH US AND TO DETERMINING THE
LEGITIMACY OF OUR PRACTICE IN A LESS
EXPENSIVE MANNER IS VERY IMPORTANT TO US.
OF COURSE LEGAL FEES FURTHER ADDS TO THE COST
OF COMPLIANCE. MY LAST SLIDE IS AN
ILLUSTRATION I WANT TO BRING TO EVERYONE'S
ATTENTION. SOMETIMES WE FEEL LIKE
WE AND OUR PATIENTS ARE CAUGHT IN THE TUNA NETS.
THE GOVERNMENT IS TRYING TO FIND THE CRIMINALS.
AND IN THEIR ZEALOUSNESS WHICH WE SHARE TO CATCH
THE CRIMINALS, SOMETIMES LEGITIMATE PROVIDERS CAN
FEEL IF NOT TARGETED, THAT THEY HAVE BEEN
CAUGHT AND REQUIRED TO ACCOUNT FOR WHAT IS
THEIR LEGITIMATE BEHAVIOR. SO I WANTED
TO EXPRESS OUR APPRECIATION FOR THE
COLLABORATION, THE OFFER FOR US TO COME IN AND
EXPLAIN WHY WE MAY HAVE OUTLYING STATISTICS.
AND ALSO, JUST -- AND WITH THE FINAL NOTE THAT
WE CONTINUE TO BE CHALLENGED WITH THE
PATIENT FREEDOM OF CHOICE THAT OUR
BENEFICIARIES HAVE. AND WITH THE NEED TO DO
THINGS CORRECTLY. WE HAVE TO HONOR PATIENT
CHOICE, EVEN IF WE ARE SEEING THE PATIENT MAY
BE MAKING BAD CHOICES. THAT, THEN, CREATES
COMPLICATIONS IN THE WAY WAY IT CREATES
COMPLICATIONS FOR DR. POLLACK.
THANK YOU VERY MUCH. [APPLAUSE]
THANK YOU VERY MUCH. AND I DO WANT TO SAY
THAT ONE OF THE GREAT BENEFITS OF THE FRAUD
PREVENTION SUMMIT FOR ME PERSONALLY HAS BEEN TO
BE REMINDED REPEATEDLY THAT WE ALWAYS TAKE TO
HEART ANYWAY, BE REMINDED OF THE NEED TO
CAREFULLY FASHION OUR NETS TO AVOID THE
PORPOISES. I WANT YOU TO JOIN ME IN
THANKING THE PANEL.