If you do not want your taxes to continue to rise and benefits continue to lower let your senators and congressmen know paying suspect claims when there is a clear indication the claims should not be paid is wrong and this should be stopped.
Recently released information on Medicare

The government paid more than $47 billion in questionable Medicare claims including medical treatment showing little relation to a patient’s condition, wasting taxpayer dollars at a rate nearly three times the previous year.
Excerpts of a new federal report, obtained by The Associated Press, show a dramatic increase in improper payments in the $440 billion Medicare program that has been cited by government auditors as a high risk for fraud and waste for 20 years.
It’s not clear whether Medicare fraud is actually worsening. Much of the increase in the last year is attributed to a change in the Health and Human Services Department’s methodology that imposes stricter documentation requirements and includes more improper payments — part of a data-collection effort being ordered government-wide by President Barack Obama this coming week to promote “honest budgeting” and accurate statistics.
Still, the fiscal 2009 financial report — covering the first few months of the Obama administration — highlights the challenges ahead for a government that is seeking in part to pay for its proposed health care overhaul by cracking down on Medicare fraud. While noting that several new anti-fraud efforts were beginning, the government report makes clear that “aggressive actions” to date aimed at reducing improper payments had yielded little improvement.
In recent years, the suspect claims have included Medicare prescriptions from doctors who were dead, and requests for payment for medical supplies such as blood glucose strips for sexual impotence and diabetic shoes for leg amputees. Patients, many of them new citizens who barely speak English, are sometimes recruited by brokers who go door-to-door offering hundreds of dollars for use of their Medicare numbers.
Obama is expected to announce new initiatives this coning week to help crack down on Medicare fraud, including a government-wide Web site aimed at providing a fuller account of health care spending and improper payments made by various agencies. The Centers for Medicare and Medicaid Services also will launch a Web interactive next month that will allow users to track Medicare payment information by categories such as state, diagnosis and hospital.
According to the report, the Bush administration from 2005-2008 reported improper payments of roughly 4 percent in the fee for service program, or about $17 billion total in 2008. Government officials at the time, however, typically did not consider a Medicare payment improper if the medical documentation was incomplete or a doctor’s signature was illegible. Since these were flaws that ordinarily bar payment, that methodology drew complaints from government auditors that the figures were understated.
For fiscal year 2009, the Obama administration began counting those claims as improper, but was unable to complete an official tally based on the new methodology. As a result, it officially reported improper payments for its fee for service program at 7.8 percent, representing a partial tally under the new formula. But it considers the unofficial tally of 12.4 percent to be more representative.
Beginning next year, the 12.4 percent figure — or a total of $47 billion in improper payments when counting both Medicare fee for service and managed care — will be used as the baseline estimate. The federal report sets a target of reducing improper payments in the fee for service program to 9.5 percent by next year, which would represent a savings of roughly $9.7 billion.
The findings come as the Obama administration is making Medicare anti-fraud efforts an important priority. In recent months, HHS has said it was multiplying by 10 the number of agents and prosecutors targeting fraud in Miami, Los Angeles and other strategic cities where tens of billions of dollars are believed to be lost each year. The new partnership seeks to have better sharing of real-time intelligence data on health care fraud patterns.
Officials say they also want to increase training and outreach among Medicare providers to reduce documentation errors, while proposed health overhaul legislation would increase background checks on Medicare claimants and impose stiffer penalties for false claims.
Other findings:
_In the Medicaid program for the poor, roughly $18.1 billion, or 9.6 percent of claims, are believed to be improper payments.
_Using a baseline of 12.4 percent in improper payments in the Medicare fee for service program, HHS is setting targets of reducing fraud and waste to 9.5 percent, 8.5 percent, and 8.0 percent, respectively, for fiscal years 2010 through 2012.
Records released in the past week showed that CMS for three years ignored internal watchdog warnings about swindlers stealing millions of dollars by scamming several Medicare programs. The agency received roughly 30 warnings from inspectors but didn’t respond to half of them, even after repeated letters.
Article written by HOPE YEN, Associated Press Writer and Hope Yen, Associated Press Writer

5. The nation’s largest hospital management company in October 2000 agreed to pay the federal government $95.5 million to settle two whistleblower lawsuits involving Medicare fraud, including for charges that the company filed fraudulent cost reports for years and that it misallocated its home health services costs.

4. St. Barnabas Hospitals: $265 million In June 2006, St. Barnabas Healthcare, a nonprofit chain of eight hospitals in New Jersey, agreed to pay $265 million to resolve charges that it systematically overcharged the government for outlier payments. While most hospitals generated just under 5 percent of their revenue from these complex “outlier” cases, St. Barnabas counted on them for a whopping 41 percent of its revenue. The government estimated damages in the case to be between $630 and $700 million, but like so many other settlements, the final amount was based on St. Barnabas’ ability to pay.

3. HealthSouth Corporation: $325 million The nation’s largest provider of rehabilitative medicine services in December 2004 agreed to pay the United States $325 million to settle allegations that the company systematically defrauded Medicare and other federal healthcare programs. Specifically, the Justice Department said the company had inappropriately billed for outpatient physical therapy services; engaged in accounting fraud; and billed Medicare for lavish entertainment and travel expenses incurred during an annual administrators’ meeting at Disney World.

2. Tenet Heathcare: $954 million
“In the annals of corporate fraud, Tenet more than holds its own among the worst corporate wrongdoers,” Sen. Chuck Grassley wrote to the company in 2003. That year, Tenet agreed to pay $54 million to settle allegations that it billed the federal government for unnecessary cardiac procedures and surgeries at one of its California hospitals.Three years later, the company agreed to fork over an additional $900 million to settle claims related to excessive outlier payments, physician kickbacks, upcoding and bill padding. At the time, it was the largest single settlement in the False Claims Act’s 150-year history, according to the False Claims Act Legal Center, a watchdog group.Tenet’s false claims tally shoots up further if you include the $324 million that National Medical Enterprises paid in kickback penalties, criminal fines and other damages in 1994 (again, a record at the time), due to fraud at psychiatric and substance abuse hospitals in nearly three dozen states. NME later renamed itself Tenet.

1. HCA: $1.4 billion The federal government has recovered nearly $1.4 billion from this healthcare giant–by far the largest recovery to ever stem from a health care fraud investigation. It began in 2000, when the huge for-profit hospital chain formerly known as Columbia/HCA pled guilty and agreed to pay the government more than $840 million for charges that included upcoding and billing Medicare for “community education” that really amounted to advertising.Three years later, HCA Inc., agreed to return an additional $631 million to the government in civil penalties and damages related to cost report fraud and paying kickbacks to physicians. And in a separate administrative settlement with CMS, the company also agreed to pay $250 million more for charges related to its cost reporting practices.

With studies showing 8 out of every 10 hospital bills having errors on them, always, always, always ask for an itemized bill. An itemized bill shows everything being billed. Medical organizations are know for not sending out an itemized bill. They typically send out a summary of all charges. This is where so many bills are paid with errors.

Don’t take “no” for an answer.

It happens every day in every kind of health care facility: Claims denials. Large and small physician offices, hospitals, specialties, and family practices lose thousands of dollars per year as a result of denied claims. Studies indicate that some hospitals lose $1,000 per day, and some outpatient facilities lose as much as $1,200 per day. Unfortunately, some facilities and practices try to mitigate the loss by passing the debt to the patient or guarantor. If you need help get a patient advocate to help you with claims. Do not assume everything is correct on your bill.

Pfizer agreed to pay $2.3 billion related to the fraudulent marketing of the anti-inflammatory drug Bextra and illegally promoting other drugs. This is the largest healthcare fraud settlement in the history of the Justice Department, the agency announced.

• Network Appliance to Pay $128 Million
  Network Appliance Inc. has agreed to pay $128 million to settle a False Claims Act case involving best price violations. This settlement is the largest corporate fraud settlement in Government Services Administration (GSA) history.
• SouthernCare Hospice to Pay $25 Million SouthernCare Inc. has agreed to pay $24.7 million to settle charges it billed Medicare for ineligible patients.
• WellCare to Pay $80 Million
  WellCare Health Plans has agreed to pay $80 million to settle charges the company inflated Medicaid charges in Florida. The settlement only applies to Florida, and does not settle any other state or federal investigations of WellCare.
• Bayer Healthcare to Pay $97.5 Million
  Bayer HealthCare has agreed to pay $97.5 million to settle an FCA case in which the company was charged with paying kickbacks to several diabetic suppliers, causing those suppliers to submit false claims to Medicare.
• Condell to Pay $36 Million
  Condell Medical Center of Libertyville, IL, has agreed to pay $36 million to settle an FCA lawsuit in which it is alleged the company paid kickbacks to doctors.

Information from Taxpayers Against Fraud

www.medicalbillrescue.com

• Amgen Pharma Fraud Alleged
  A qui tam case against Amgen over the sales and marketing of arthritis and psoriasis drug Enbrel, and anti-anemia drug Aranesp, has come out from under seal due to a judge’s order. DoJ is still deciding if it is going to join. Amerisource-Bergen and online health-information provider WebMD Health Corp are also named in the complaint, which involves off-label marketing, kickbacks and Medicaid best price violations.
• DoJ Joins Natrecor Suit
  The U.S. Justice Department has joined two whistleblower lawsuits alleging that Johnson & Johnson and Scios engaged in off-label marketing of the cardiac drug Natrecor.
• Biomet and Others Under Investigation
  A whistleblower lawsuit accuses Biomet Inc. and several other orthopedic companies of defrauding the U.S. Government of hundreds of millions of dollars by making false payment claims.
• California Sues Seven Labs
  California is suing seven private medical labs, alleging they cost the state hundreds of millions of dollars by overcharging Medicaid of California (Medi-Cal) by as much as 400 percent.

• Lilly Pays Record $1.4 Billion
  Eli Lilly has agreed to pay $1.4 billion to settle charges it defrauded Medicare and Medicaid by off-label marketing of Zyprexa. Of the $1.4 billion settlement, $800 million is to be paid under the FCA ($438 million under Federal FCA, $362 million to the states), and $615 million is a criminal penalty.
• Northrop to Pay $325 Million
  Northrop Grumman has agreed to pay $325 million to settle a False Claims Act lawsuit that alleges TRW (now owned by Northrop) made defective parts for spy satellites that resulted in serious malfunctions and expensive fixes, all charged to U.S. taxpayers. The Northrop settlement is the largest military-procurement fraud whistleblower case to date.
• Quest Diagnostics to Pay $302 Million
  Quest Diagnostics has agreed to pay $302 million to settle civil and criminal charges related to a Quest subsidiary which sold a parathyroid hormone immunoassay test which reported elevated results.

Information supplied from Taxpayers Against Fraud

Any questions on how to potentially stop fraud cases contact us at www.atozmedicalaudits.com

In a new report, “Coverage Denied: How the Current Health Insurance System Leaves Millions Behind,” the U.S. Department of Health and Human Services examines the insurance company practice of denying coverage to or discriminating against Americans who have pre-existing medical conditions. A recent national survey found that 12.6 million non-elderly adults — 36 percent of those who tried to buy insurance on the private market — were discriminated against in the past three years because an insurance company deemed them ineligible for coverage because of a pre-existing condition, charged them a higher premium, or refused to cover their condition. Another survey found 1 in 10 people with cancer said they could not get health coverage, and 6 percent said they lost their coverage because of their diagnosis.

The insurance company practice of denying coverage because of pre-existing conditions is not confined to serious diseases.   Even minor problems such as hay fever could trigger prohibitive responses. An insurer could charge high premiums, deny coverage, or set a restriction such as denying any respiratory disease coverage to a person with hay fever, according to the report.

What’s more, some insurance companies respond to an expensive condition such as cancer by initiating a thorough review of the patient’s health insurance application.  If the company discovers that any medical condition, regardless of how minor, was not reported on the application, it could revoke coverage retroactively for the patient and possibly all members of the patient’s family, the report said. The practice is known as rescission.

Companies can do this even if the condition found is not related to the expensive condition or if the person wasn’t aware of the condition at the time.

At least one company encouraged employees to revoke sick people’s health coverage through rescissions, the report said.

Under health insurance reform, insurance companies would be prohibited from refusing coverage based on someone’s medical history or health risk. Companies also would be barred from watering down coverage or refusing renewal because someone becomes sick. Companies would have to renew any policy as long as the policyholder pays the premium in full. 

The new report is available at www.HealthReform.gov.

News Release from Center for Medicare and Medicaid Services on 09-11-2009

• Pfizer‘s $2.3 Billion Reserve
  Pfizer’s SEC report notes the company has reserved $2.3 billion “resulting from an agreement in principle to resolve previously disclosed investigations regarding allegations of past off-label promotional practices concerning Bextra, as well as other open investigations.” When a settlement occurs, this will make Bextra the largest single settlement with an FCA component.
• Glaxo’s $400 Million Reserve
  GlaxoSmithKline has reserved $400 million to settle off-label and kickback charges related to “several products” sold from 1997 to 2004, including the antidepressant Wellbutrin. Glaxo said the reserve “reflects the current status of the [DoJ] investigation.”
• Forest’s $170 Million Reserve
  Forest Laboratories has set aside $170 million to settle a False Claims Act case related to kickbacks paid to doctors for prescribing antidepressants Celexa and Lexapro to children, as well as for the off-label marketing of Levothroid. Forest notes that “there can be no assurance that the amount reserved by the Company will be sufficient and that a larger material amount will not be required.”
• Merck Faces 35 States on Vytorin
  DoJ and 35 state Attorney Generals offices are investigating whether Merck and Schering-Plough improperly promoted the cholesterol drug Vytorin. Merck says it has received five “civil investigative demands” from a multistate group.
• Risperdal Marketed Off-label
  Three former salespeople have filed suit against Janssen Pharmaceutical alleging the company engaged in off-label marketing of the antipsychotic drug Risperdal. According to the lawsuit, company salespeople were encouraged to push the drug to doctors as a treatment for bipolar disorder and depression. Risperdal generated $3.4 billion in sales in 2008. This case seems to be parallel to the Lilly/Zyprexa case settled for $1.4 billion in January, and an analog case dealing with Seroquel is out there. Wellcare has already paid out approximately $80 million already, but there are other ongoing investigations, a and the CEO just resigned (the second in as many years).

Information supplied by Taxpayers Against Fraud

Hospital records were sometimes falsified to cover up medical mistakes

BY Robert Gearty, Benjamin Lesser and Greg B. Smith
DAILY NEWS STAFF WRITERS

Sunday, July 26th 2009, 3:05 AM

Some staffers at city-run hospitals have practiced a very nonmedical skill — fiction writing.

Doctors, nurses and support staff have made false entries in hospital records to cover up medical screwups, a Daily News investigation found.

Records sometimes lacked crucial data or were missing completely, making a thorough investigation impossible.

Again and again, workers at city-run hospitals faked records to cover up incidents or claimed they couldn’t find data when investigators came knocking.

Between 2004 and September 2008, the state issued 16 citations for incomplete, altered or missing medical records, a News analysis of hundreds of pages of internal documents found.

BELLEVUE HOSPITAL

Records were sometimes ludicrous. At Bellevue, for instance, medical reports listed a psychiatrist performing surgery.

Sometimes, as in the case of patient Alfred Scott, they were anything but funny. Scott showed up at Bellevue Sept. 8, 2005, diagnosed as having suffered a “cardiac event.” A fourth-year med student placed an IV in his left arm.

Problem No. 1: Students are not allowed to administer IVs.

Over the next two days the medical student and several nurses made apparently fictional entries in medical records.

The student claimed Scott’s arm was fine. One nurse wrote that the arm’s skin was “warm to touch.” Another says there were “no signs of inflammation.”

Problem No. 2: Scott’s arm was covered from knuckles to elbow with a material called Kerlix which made examination impossible. When the Kerlix was removed after two days, staffers found Scott’s arm was “blistering,” his left hand “cool to touch and pulseless.”

Investigators concluded “the student likely did not examine the left arm” and that the signs of problems “must have been present during the time that nursing staff documented intact skin and circulation.”

Surgeons determined the IV made Scott’s arm “not salvageable.” Three days after surviving a heart attack, Scott had his left arm amputated at the elbow.

Besides the fictional notes, hospital records make another false claim: that a licensed medical doctor administered the IV.

Scott died four months later. His widow, Gwendolyn, sued, saying the amputation contributed to his death. The hospital was fined $14,000, but the family was not told.

In a statement, the city Health & Hospitals Corp. confirmed “protocol prohibits medical students from starting IVs” and blamed the nurse for “mistakenly” thinking the med student was a resident.

Because of this incident, HHC banned using dressing that obscures an IV site and required nurses to check IVs every day.

WOODHULL HOSPITAL

The hospital turned over “corrected” records when investigators showed up to look into a March 2007 incident in which a 3-month-old infant died.

The infant arrived at Woodhull March 25 with difficulty breathing and spiking a temperature of 102. At the time the hospital relied on a doctor who specialized in cardiac care for children, but that weekend, the doctor was out of town.

Two pediatric residents who weren’t supposed to examine critical care patients without direct supervision did the exam. They recommended continuous nebulizer treatments, but they did not give this information to the attending physician.

The attending first learned this eight hours after the child arrived, when he examined the infant for the first time and recommended “close observation.”

After this, the report notes, the infant began suffering “severe respiratory distress,” and by 8 p.m. the hospital finally contacted the pediatric heart specialist.

That doctor recommended transferring the child to another hospital because he was out of town. At 2:15 a.m. the next day the child was transferred “with spastic tremors of face and arms.” The child died within 24 hours of the transfer.

Though hospitals are supposed to report incidents like this within 24 hours, the state did not learn of this incident for a month.

Investigators found the hospital’s medical files did not identify an attending physician on duty when the infant was there. The next day, the hospital produced a “corrected” record naming the doctor on duty.

The hospital insists it always had adequate doctors on hand but was cited for numerous violations, including failing to report the incident in a timely manner. It was fined $10,000.

JACOBI MEDICAL CENTER

In many cases, problems included simply losing medical records and failing to properly track patient care and status.

Jacobi Medical Center in the Bronx was cited on five separate occasions for these problems, records show.

On April 8, 2004, a woman delivered a stillborn infant at Jacobi. The state found key sections of her medical records missing.

The citation said the missing records made it impossible for the facility to properly review the care the mother was given prior to the stillborn birth.

HHC called this a case of “misplaced paper” that was eventually found.

In some cases, HHC hospitals take their time about investigating incidents.

Records show a Harlem Hospital Center patient died after staff failed to properly respond to repeated episodes of severe bleeding. Staff did not investigate the cause of the bleeding until at least 10 days after the problem began and had still not completed it when the patient died less than three weeks later.

Information per : http://www.nydailynews.com/ny_local/2009/07/26/2009-07-26_hospital_records_were_sometimes_falsified_to_cover_up_medical_mistakes.html?page=0#ixzz0MZ7GrFcY