First Amendment Coalition » Medicare fraud

Insurance analyst says her reporting Medicare fraud got her fired

donal brown — Mon, 09 May 2011 18:46:15 +0000

A Michigan insurance analyst is suing Priority Health Managed Benefits for firing her for reporting fraud after they asked to narrow her focus and ignore deletes or false or incorrect codes that would bring the company Medicare over payments.

The analyst felt the company was asking her to commit fraud and called the Medicare hotline in January. In February she and four other analysts were fired.

From the Courthouse News Service, May 09, 2011, by Glynis Farrell.

Full story

Wall Street Journal sues for access to Medicare fraud database

donal brown — Tue, 25 Jan 2011 18:57:03 +0000

The Wall Street Journal has filed to overturn a longstanding injunction that blocks access to records of Medicare fraud and the doctors implicated in the fraud. -db

Dow Jones
Press Release
January 25, 2011

NEW YORK – The publisher of The Wall Street Journal filed court papers today to overturn a 31-year-old court injunction that blocks public access to records containing evidence of Medicare fraud and the doctors behind it.

The filing by Dow Jones & Company, in the U.S. District Court for the Middle District of Florida, seeks to overturn an injunction obtained by the American Medical Association in 1979. The injunction prevents the public from knowing how much taxpayer money individual doctors receive from the Medicare program. As a result, The Wall Street Journal and other news organizations are barred from fully investigating and exposing abuses in the $500 billion system.

The legal action follows a series of articles in The Wall Street Journal last year, “Secrets of the System,” that relied on a sampling of the government’s closely guarded Medicare databases. The series highlighted suspicious billing, potential abuses of the system and the government’s role in policing Medicare payments.

However, the 1979 injunction constrained the Journal’s investigation and what it could tell its readers because it limited the Journal to only a subset of the data. In addition, the government would only release the limited subset of data if the Journal agreed not to disclose the identities of individual doctors in the databases.

“It is time to overturn an injunction that, for decades, has allowed some doctors to defraud Medicare free from public scrutiny,” said Mark H. Jackson, general counsel for Dow Jones. “The public has a significant interest in learning whether doctors are fleecing the system, the extent of the problem, and whether the government has been effective in stopping such abuse.”

This effort will not compromise patient confidentiality, Jackson added.

“The Medicare system is funded by taxpayers and yet taxpayers are blocked from seeing how their money is spent,” said Robert Thomson, editor in chief of The Wall Street Journal. “It is in the interests of law-abiding practitioners that those who are gaming the system are exposed. Unless funds are used efficiently and intelligently, the health of the nation, physically and fiscally, will be undermined.”

The Journal series revealed how Medicare reimbursement policies and doctors’ relationships with private companies in the industry could be giving doctors an incentive to bill for unnecessary and high-cost procedures. It also reported on several doctors with questionable billing practices, including one doctor who took home more than $2 million from Medicare in 2008 by billing for an improbable number of obscure medical tests and another who received more than $8.1 million from Medicare over three years while treating a suspiciously high percentage of patients with an extremely rare condition. Because of the injunction, neither doctor could be named in the articles.

The law firm of Davis Wright Tremaine LLP is representing Dow Jones in this matter.

Medicare payment data to go onto public Web site

donal brown — Fri, 20 Nov 2009 17:42:51 +0000

The Center for Medicare is planning to put up information about Medicare payments onto a Web site so that the public can track where the money is going. Some are concerned that this way of ferreting out fraud may also result in invasions of privacy. -DB

NextGov
November 19, 2009
By Aliya Sternstein

The Obama administration plans to launch a Web site in December that the public can use to monitor Medicare payments, but some health care specialists say it will be difficult for the application to expose fraudulent payments and protect privacy at the same time.

The Web site will allow people to view the number of health services performed and payments, organized by state, diagnosis and hospital, according to officials at the Centers for Medicare and Medicaid Services.

“Controlling wasteful spending in health care is one of the ways of fixing our health care system — at the same time it’s critical that protections be in place to make sure the information provided by this tool doesn’t [reveal details] that can be attached to a person’s name,” said Larry McNeely, a health care reform advocate at U.S. PIRG. The organization works to defend public health, consumers and privacy.

The CMS initiative is part of a governmentwide push to root out waste in federal spending through public Web sites that track the money. Such tools include Recovery.gov, the stimulus monitoring site, and the IT Dashboard, which aims to shed light on investments that are over budget or behind schedule. By recruiting Internet users as volunteer watchdogs, the government is attempting to establish citizen trust and convey a sense of transparency and accountability.

In a related development, CMS late Tuesday night reported the error rate of Medicare claims for inpatient hospital services more than doubled in 2009. The higher rate — now 7.8 percent, or $24.1 billion, compared with 3.6 percent in 2008 — is attributed to a calculation change to reflect a more complete accounting of improper payments, according to officials.

McNeely said it would be useful to view the number of MRIs a hospital orders to determine whether the institution is abusing payments to cover the cost of equipment.

But he noted that diagnosis coding for individual hospitals — even if stripped of patient identifiers — could compromise privacy when the illness indicated is rare. Federal officials should ensure diagnosis descriptions are not too specific or else exclude extremely rare illnesses, McNeely said.

Releasing details on atypical diagnoses is less of a problem at the state level, but state-level data generally is not as revealing as hospital-specific information, other specialists said.

Privacy could be protected if the sample size is large enough and the data is stripped of patient names, addresses, phone numbers and at least the last one or two digits of a 5-digit ZIP code, said John F. Quinn, a senior executive with the health care practice at consulting firm Accenture.

“I am not too concerned about patient privacy as long as a qualified statistician is employed to review and analyze the type of data being gathered and certifying that the selection processes in fact meet the requirements of ensuring patient privacy,” he said.

But that is not a simple feat, Quinn added, echoing concerns about the ability to trace back through claims for a relatively rare diagnosis to reconstruct a patient’s identity. “So it does take some skill” for statisticians and officials to protect information properly, he said.

Another challenge for the government will be the tendency to jump to conclusions about anomalies — relatively expensive surgeries or repeat orders — without all the facts, said Steve Findlay, senior health policy analyst at Consumers Union, publisher of Consumer Reports.

“That outlier hospital might tell you, ‘We see the most complicated cases.’ That’s generally not true. That excuse doesn’t hold water most of the time,” he said. “But you can’t automatically call it fraud. You have to look into it.”

The public, and government officials, likely will need more information than what the site offers to understand the complexity of cases, Findlay said. For example, the aberrant hospital might have only performed a costly procedure five times for especially severe illnesses.

Government watchdog groups have limited expectations for the site.

“Given the level of waste, fraud and abuse in Medicare and Medicaid, the new data could be a useful method for oversight of tax dollars, but I wouldn’t expect miracles,” said Pete Sepp, spokesman for the National Taxpayers Union, a group that advocates for lower taxes and smaller government. “Waste can be a systemic problem, but fraud and abuse are human acts, which can be more difficult to discern by simply searching through a database.”