Granny Bird Award: Doctors Who Write Questionable Prescriptions

This edition of the Granny Bird Award, given from time to time by those who adversely affect the rights and benefits of elders, goes to those doctors identified in a recent report as issuing prescriptions for questionable drugs or over-prescribing medications as identified in a recent report noted in the Washington Post.

More than 700 doctors nationwide wrote prescriptions for elderly and disabled patients in highly questionable and potentially harmful ways, according to a report of Medicare’s drug program released Thursday.

The review by the inspector general of the Department of Health and Human Services flags those doctors as “very extreme” in their prescribing and says Medicare should do more to investigate or stop them. ...

The inspector general’s report focused on the prescribing by nearly 87,000 general-care physicians, such as family practitioners and internists, in urban and suburban areas in 2009. These doctors accounted for about half of all the prescribing in the program that year.

The review found more than 2,200 doctors whose records stood out in one of several areas: prescriptions per patient, brand-name drugs, painkillers and other addictive drugs, or the number of pharmacies that dispensed their orders.

Of those, 736 were flagged as “extreme outliers.” Their patterns, the report says, raised questions about whether the prescriptions were “legitimate or necessary.” ...

The cost to the government was enormous in some instances. Medicare paid $9.7 million for the prescriptions of one California doctor alone — that is 151 times more than the cost of an average doctor’s tally, the report says.

Most of this physician’s drugs were supplied by two pharmacies, both of which the inspector general had identified previously as having questionable billing practices.   [Emphasis added]

Whether for fraudulent purposes or because of just plain sloppy medical management, these doctors cost Medicare/Medicaid a ton of money.  At a time when this very important program for elders and the disabled is under attack by all parts of the federal government, such behavior is extremely angry-making and needs to be stopped in its tracks now.  Hopefully CMS and the DOJ will come down hard on the miscreants.

Granny Bird Award: Medicare Fraudsters

This edition of the Granny Bird Award, an award issued from time to time to those who harm the interests and benefits of the elders, goes to those who are fraudulently collecting money from Medicare.

From McClatchy DC:

Doctors, nurses and other licensed medical professionals were among 89 people recently arrested in nine cities, accused of scheming to defraud the Medicare program of nearly $223 million in false billings, the Obama administration announced Tuesday.

The defendants face charges of conspiracy to commit health care fraud, money laundering and violating federal anti-kickback statutes for submitting claims to Medicare for purchases, treatments and services that, according to federal officials, either were medically unnecessary or never provided.

In many cases, patient recruiters, Medicare recipients and others were paid cash to supply beneficiary information that later was used in billing scams, federal law enforcement officials said. Most of the alleged fraud involved home health care services, but the charges included mental health services, psychotherapy, physical and occupational therapy, durable medical equipment and ambulance services. ...

Over the past three fiscal years, every dollar spent fighting health care fraud has returned an average of nearly $8 to the U.S. Treasury and the Medicare Trust Fund, Holder said. But that success is threatened by the across-the-line federal budget cuts known as sequestration, which cut $1.6 billion from the Justice Department’s budget for the current fiscal year, he said.   [Emphasis added]

The illegal conduct was spotted by the Center for Medicare/Medicaid Services (CMS) primarily by a sophisticated computer program, but also by elders who checked the report from CMS each receives regularly and noted charges for goods and services they did not receive.  In other words, CMS is doing its job, but needs elders to do theirs as well.

While I am not Eric Holder's biggest fan, I do think the DOJ has been doing its job well in prosecuting Medicare fraud.  I hope the sequester is lifted soon so that we can continue to nail the sleazes who would rob the system so vital to elders.

Granny Bird Award: CVS

This edition of the Granny Bird Award, given from time to time to those who go out of their way to harm the interests and benefits of elders, goes to CVS, the pharmacy chain which has gone into the Medicare business by offering a Part D benefit.  They roped in a lot of elders with their promises of lower prescription prices and then did a bait-and-switch on them.

The federal Centers for Medicare and Medicaid Services said in a letter to CVS' SilverScript subsidiary that its inability to process prescriptions correctly "poses a serious threat to the health and safety of Medicare beneficiaries."

The federal agency blamed the problems on "widespread data system failures" that have "created disruptions in tens of thousands of Medicare beneficiaries' access to prescription medications."

SilverScript handles the drug requirements of about 4 million Medicare beneficiaries.

In Shapiro's case, she told me that she'd ordered a 90-day supply of an estrogen pill that was supposed to cost $85. Instead, SilverScript sent her a 30-day supply running $70.61.

Shapiro said she got the runaround from three separate CVS supervisors until a company representative finally insisted that she had to take what she was given and pay the amount CVS was demanding. ...

Medicare says it received 2,340 complaints about SilverScript in just the first two weeks of January — a rate four times greater than for all other Medicare-approved drug programs combined.   [Emphasis added]

Go read all of David Lazarus's column (link above) to see the lame excuses being offered.  Then write the White House and urge that they push to remove CVS from the approved list of Part D providers. 

Why We Can't Have Nice Things

(Editorial cartoon by Jim Morin / Miami Herald (January 10, 2013) and featured at McClatchy DC.  Click on image to enlarge and then hustle back.)

Although Jim Morin's cartoon is directed toward Medicare, I think it applies to Medicaid as well, especially since the two programs are often lumped together during budget talks.  That said, I am particularly interested in the buttons labeled "Fraud" and "Lax Oversight."  I've mentioned Medicare fraud in several prior posts, usually via a Granny Bird Award.  The same principles apply to this one.

Medicaid is usually administered, at least partially, by the states, and a recent article in the Minnesota Star Tribune details one such case of fraud.

The operator of a home health care agency in northeast Minneapolis stands accused of filing bogus Medicaid billings totaling more than $400,000, his second legal round of legal trouble while a businessman in the city.

Abshir M. Ahmed, 40, of Minneapolis, was charged Tuesday in federal court in Minneapolis with health care fraud. Ahmed was charged via information, indicating that he intends to plead guilty.

According to prosecutors, from January 2008 through June 2011, Ahmed submitted false claims through Lucky Home Health Care Inc. for services by personal care assistants that were not carried out.  [Emphasis added]

That's pretty much the same modus operandi used by Medicare fraudsters.  The scams go undetected for a long time both because some of the regulations are loosely written and because the claims are just accepted and paid unless someone notices something peculiar.  Especially in state cases, this can happen often because the regulatory agency just doesn't have enough funding to review each submitted claim carefully.

The Obama administration has done a pretty good job in discovering and shutting down fraud in the Medicare arena.  It would be nice if the feds and states would take the same stance on Medicaid, perhaps with regulation-tightening and with funded investigations.  Half a million dollars may not sound like much, but it mounts up quickly across time and across the country.  It's time to do some pushing here.

Granny Bird Award: Charles Agbu

This edition of the Granny Bird Award, given from time to time to those who harm the rights and lives of elders, goes to Charles Agbu, who has copped a plea in a Medicare fraud case.

A Carson pastor pleaded guilty Monday to submitting more than $11 million in Medicare reimbursement through fraudulent clinics and by promising patients expensive equipment, according to the Department of Justice.

Charles Agbu, 58, of Carson, pleaded guilty to one count of conspiracy to commit healthcare fraud and one count of money laundering in U.S. District Court.

Agbu, a pastor at Pilgrim Congregational Church, faces up to 20 years in prison and a $500,000 fine when he is sentenced in May.

Agbu admitted to owning Bonfee Inc., a fraudulent medical equipment supply company, and acknowledged that he paid patient recruiters to approach Medicare beneficiaries and convinced them to give him their Medicare information in exchange for specialized power wheelchairs, officials say.

Agbu would then bill Medicare officials for the wheelchairs without delivering them to his clients. He also admitted to paying for fake prescriptions and other fraudulent documents in order to be able to continue  billing Medicare for medical equipment, authorities say.  ...

The case was brought by the Medicare Fraud Strike Force, a special unit of investigators launched in May 2009 by the Justice and Health and Human Services departments.   [Emphasis added]

Apparently "Pastor" Agbu wasn't too familiar with the Ten Commandments, especially that one about lying.  Some attribute for a man of God.

While the article isn't clear as to how much money the good "pastor" reaped by his scam, the fine does seem a little low, even by plea-deal standards.  That 20 years in prison, however, does seem appropriate and I hope the judge gives him all 20 years.  That will at least send a message.

Finally, at a time when the vile idiots in Washington are considering cuts to Medicare/Medicaid, perhaps that could be accomplished by tightening up the language of the original legislation which left loopholes for this kind of fraud to be accomplished.  The Center for Medicare/Medicaid Services, the agency charged to oversee such billings needs to be ramped up so that it can spot these scams before they hit the $11 million mark.  And more money to the agencies investigating such fraud (DOJ and HHS) would also be helpful in rooting out the wrongdoers, recovering their ill-gotten gains, and slamming their backsides in prison for long terms.

Let your congress critters know that these are the only kind of "cuts" to Medicare/Medicaid which are acceptable and do it today.   

Post Mortem

OK, I listened to all but the last 15 minutes of Wednesday night's debate, and, frankly, I was bored.  Obviously (given all the ink and electrons spilled in analyzing the event), I may have been one of the few.  I will admit that President Obama came out listless and ill-prepared and Mitt Romney came out energized and in full take-over mode.  That did somewhat surprise me, but both obfuscated and lied through much of the part I did watch, which did not surprise me.

David Horsey watched the event with friends (as did many people) and his take is somewhat instructive.

Over the 90 minutes of the debate, Romney submerged the right-wing image he had adopted in the Republican primary race and came off as a reasonable, moderate technocrat who differs with President Obama only about the means to get to the ends they both seek.

For his part, Obama was pleasant and professorial, as if he were merely engaged in a ponderous academic discussion, rather than a political grudge match with enormous consequences. Faced with the chance to deliver the coup de grace to Romney’s flailing campaign, Obama appeared to have left his rhetorical weapons at the door.

Without the president calling him on it, Romney expressed a newfound concern for the poor that differed dramatically from the disdainful tone of his private remarks about the 47% of Americans he describes as dependent, indolent victims. He rolled over debate moderator Jim Lehrer and took the fight to Obama on everything from green-energy funding to Obamacare.   [Emphasis added]

Obama made no mention of Bain, of off-shore tax havens, of the "47%".  There was certainly an opportunity for each of those.  There was no mention of yet more Romney's trademarked flip-flops, although that might have required a little finesse and a willingness to throw-down, something Mr. Obama clearly hates to do on his own.

And that's a shame, because on the issue of Medicare/Medicaid and Romney's assertion that the president "cut" $716 million from Medicare, Obama had available to him some news that would have bolstered his assertion that the cuts were to fraudulent and unethical providers and not to beneficiaries.

A federal healthcare strike force has charged 91 doctors, nurses and other licensed medical professionals in a nationwide sweep in connection with fraudulently billing the government nearly $430 million. Those charged included a group in Los Angeles that ferried patients for ambulance rides that were never medically necessary.

According to federal law enforcement officials on Thursday, 16 people were charged in Los Angeles, including three doctors and a licensed physical therapist, in schemes that cost $53.8 million. The phony ambulance trips cost the government $49.2 million, and the four people arrested in that operation represent the largest takedown of alleged ambulance fraud since the special Medical Care Strike Force was activated five years ago. ...

Since May 2007, strike force officials working under the Department of Justice and Department of Health and Human Services have charged more than 1,480 defendants for more than $4.8 billion in healthcare fraud.  [Emphasis added]

 As disappointed as I have been with President Obama, his work on rooting out the rogues in healthcare has been magnificent and long-overdue.  That is how the savings to Medicare/Medicaid will be worked out, and that is a good thing as far as containing rising healthcare costs.  Emphasizing that in response to Romney's smarmy allusion to the "unelected" panels (a nice dog-whistle for death panels), would have been appropriate, yet Obama pretty much let that go.

Will this first debate make a difference as far as the election goes?  Who the hell knows.  It does give the pundits and mainstream press what they wanted:  a way to keep touting a close race which may or may not exist.  It also keeps the tv stations happy because it means the political ads will keep adding to their coffers for the next month.

Will I pay attention to the next debates?  Probably, but my expectations will be even lower.  In other words, I'm not buying any more popcorn.

Granny Bird Award: Abbott Laboratories

Last December, I issued a Granny Bird Award (given from time to time to those who have an adverse effect on the health, welfare, and rights of elders) to those doctors, nursing home operators, and pharmaceutical companies who allow the off-label use of powerful antipsychotic drugs to pacify nursing home patients with dementia.

It now turns out that not only antipsychotic drugs are being used off label for this purpose. And it also turns out that Abbott Laboratories, the current recipient of this award, went out of its way to sell Depakote for such a dangerous off-label use.

Global pharmaceutical giant Abbott Laboratories has agreed to pay federal and state governments $1.6 billion in criminal and civil fines for illegally promoting unapproved uses of its drug Depakote, including to sedate elderly patients in nursing homes, officials announced Monday.

The settlement, which includes an agreement to plead guilty to a criminal misdemeanor, is the second-largest in a string of multimillion-dollar payouts in recent years resulting from stepped-up enforcement by the Justice Department and state investigators against drugmakers that “misbrand” their products. ...

“Not only did Abbott engage in off-label promotion, but it targeted elderly dementia patients and down-played the risks apparent from its own clinical studies,” Tony West, acting associate attorney general, said in a statement. ...

The attorney for Meredith McCoyd, one of four former Abbott sales representatives whose whistleblower lawsuits prompted the investigation, said the company offered nursing homes a second rationale.

“Abbott directed its sales force to get Depakote widely used in nursing homes, principally to neutralize older patients as a substitute for proper staffing,” attorney Reuben Guttman said in a statement. “Abbott essentially preyed on the most helpless patient populations.” [Emphasis added]

Depakote is a drug which is designed for neurological disorders such as epilepsy, not to pacify dementia patients. Further, the company's own clinical studies showed that such use was dangerous and had disastrous side effects such as dehydration. That didn't stop it from touting the benefits of keeping such difficult patients loaded to save nursing home staffing costs, nor did it stop it from offering some bakshish to pharmacies which service such nursing homes rebates for increasing sales to them.

The fine is a stiff one relatively speaking (you know the old saying, "a billion here, a billion there, pretty soon you're talking real money), but don't worry about Abbott Labs. They are doing just fine according to last year's numbers:

Revenue $39 billion
Net Income $5 billion

While it is gratifying to see such a large "fine" levied, I would have been happier with really serious criminal sanctions. I would like to have seen the marketing guru who came up with this scam and all of his superiors right up the line arrested and facing years in prison for fraud and everything else the states and feds could come up with. That's the only way PHARMA will get the message.

But I guess that's asking too much right now.

Credit Where Due

Sometimes the Obama administration gets it right, and this is one of those times.

Doctors, nurses and social workers from across the country, 107 in all, were charged in what federal officials in Washington called a "nationwide takedown" of medical professionals accused of fraudulently billing Medicare out of nearly half a billion dollars.

The amount of bogus Medicare claims, totaling about $452 million, was the highest in a single raid in the history of a federal strike force combating rising fraud in the medical industry, according to the Justice Department. Arrests were made in seven major cities. ...

In addition, officials in the Health and Human Services Department suspended or took other administrative actions against 52 medical providers after analyzing billing requests and finding additional "credible allegations of fraud." ...

The Obama administration has stepped up efforts to combat fraud in the Medicare program, which provides health coverage to about 50 million elderly and disabled Americans.

Last year the federal government charged 1,430 people with healthcare fraud, up from 797 in 2008, according to the Health and Human Services Department. The agency also reported revoking the eligibility of more than 60,000 Medicare and Medicaid providers and suppliers and recovering $4.1 billion in fraudulent claims. [Emphasis added.]

President Obama, Health and Human Services Secretary Sebelius, and Attorney General Holder should all be congratulated for their increased efforts in combating fraud in the Medicare program. Obviously, there's still a lot of weeding out that needs to be done, and the work has to be done more quickly, but the increase in funding, in investigative technology, and in manpower is finally in place.

The trick will be to keep that funding in place. Some of the increase came from a section of the ACA, and the Supreme Court might very well rule the entire act unconstitutional, thereby drying up a crucial source of money to pay for the program. If that happens, I hope the administration twists the necessary arms in Congress to find another source and find it quickly. Shutting down the fraud is a key step in restoring some fiscal stability to this important government program.

Some More Good News

After three plus years of threatening to cut/privatize/end Medicare from the GOP and, in a somewhat muted fashion, the White House, we finally are getting some news that might suggest to those idiots a better way to cut the costs of this program which is so vital to the elders in our country.

Federal law enforcement officials announced charges in the largest healthcare fraud scam in the nation's history, indicting a Dallas-area physician for purportedly bilking Medicare of nearly $375 million after he reportedly sent out "recruiters" to round up patients and get them to sign for treatments he never provided. [Emphasis added]

Go read the story to see how this doctor set up his scheme (a nifty graphic shows the 'companies' he set up to keep under the radar). The raid on his home picked up records from a Cayman Islands bank, a passport along with several different passport photos, and the like. This guy way ready to leave at a moment's notice, but he wasn't given the time by the DOJ.

Here's what I considered to be the important part of the story:

Atty. Gen. Eric H. Holder Jr., in testimony Tuesday before a House Appropriations subcommittee, said federal prosecutors were fighting back. In the last fiscal year they recovered nearly $4.1 billion in funds "stolen or taken improperly from federal healthcare programs," he said. "This represents the highest amount ever recovered in a single year."

At the same time, Holder said, the Justice Department opened 1,100 new criminal healthcare fraud investigations, won more than 700 convictions, and initiated 1,000 civil healthcare fraud investigations.

In all, he said, for every dollar spent fighting healthcare fraud, "we've been able to return an average of $7 to the U.S. Treasury, the Medicare Trust Fund" and other government entities.

That's not a bad return on the investment, and if the DOJ succeeds in reclaiming that $375 million in this case from the Cayman bank account and gets a hefty fine, the figure should be even higher this year.

Yes, the investigations are long and costly, but this proves it's worth it. And, yes, the laws and regulations currently in place for Medicare and other health programs are complex. Then clean both parts up. These programs and this country's elders and other vulnerable citizens deserve it.

And Attorney General Holder: more like this please.

Granny Bird Award: RehabCare Group Inc.

Unfortunately, it's time for another Granny Bird Award, given from time to time to those who make it a point to harm elders in some egregious way. This time it goes to a fraudster, someone bilking our system.

Intervening in a lawsuit by a Minnesota whistleblower, the U.S. Justice Department has sued a large health care company based in Kentucky, alleging that it paid more than $10 million in kickbacks for access to Medicare and Medicaid patients living in a chain of nursing homes.

In a civil complaint filed in Minneapolis, the U.S. attorney said RehabCare Group Inc. began making illicit payments in 2006 as part of a deal with Missouri businessmen who owned 62 nursing homes in their state and an in-house company that provided health services to the residents. The deal was premised on RehabCare's plan to take control of the services and expand billings under Medicare and Medicaid, the complaint said.

"The suggestion was straightforward: Facilities that contracted with RehabCare could expect [it to] provide more therapy to the facilities' beneficiaries, and as a result, the facilities would make more money,'' said the complaint filed by Assistant U.S. Attorney Chad Blumenfield.

The recipient of the alleged kickbacks, Rehab Systems of Missouri LLC (RSM), received an initial $600,000 payment and a cut of more than 10 percent of RehabCare's ongoing billings, which have exceeded $70 million since 2006, the suit said.

The litigation is based on a federal anti-kickback law that makes it illegal to pay others for referrals of Medicare patients. Patients are supposed to receive services based on their medical needs, not as a result of financial inducements paid to their health care providers. The lawsuit seeks fines and financial recoveries. [Emphasis added]

$70 million, much of it for unnecessary treatment. That's a lot of money flowing out of our system. Fortunately, a whistleblower stepped up and reported the scam. We can't, however, always count on some honest soul to do the reporting in each case. Those of us who receive Medicare have a role to play as well.

First of all, we need to remember to guard our Medicare card and our policy number. People offering us a free lunch so that they can offer us some "free tests" don't need either.

Second of all, Medicare sends out regular reports with itemizations of billings they have received for our accounts. We need to read those reports as soon as they arrive and not just toss them as junk mail. If an item appears that doesn't seem right to you, such as a motorized wheelchair when you don't need any such assistance or a diagnostic test you never received, notify Medicare immediately by phone (or on their web site). Medicare adjusters will look into it, and if they see a pattern of such abuse from a provider, they will report it to the Department of Justice.

Third, Congress and the White House keep looking for ways to cut the cost of Medicare. You might let both know that one way to contain costs is to go after Medicare Fraud and to go after it hard. If it means giving more funding to the DOJ, then so be it. The system could save millions every year just by prosecuting and fining these con artists, far beyond what it might cost to fund a special unit to do the work.

We really do need to start making some noise, especially these days.

Medifraud

It appears that the Obama administration is getting serious about fraud in the Medicare and Medicaid systems. One official, Peter Budetti, deputy administrator and director for the Centers for Medicare and Medicaid Services' Center for Program Integrity even responded to an Los Angeles Times opinion piece which attacked Medicare's electronic billing system as one just made for the criminals to take advantage of.

Here's a few of his comments from that response:

Since President Obama took office, we have conducted an unprecedented crackdown on those who steal from Medicare, giving law enforcement greater resources, putting more boots on the ground and increasing penalties. In 2010, these efforts recovered a record $4 billion in taxpayer money.

But we're not just prosecuting fraud. We're also taking steps to prevent it. In the past, nearly anyone could fill out a form with the right information and become a Medicare provider. Criminals could set up false clinics, enlist willing accomplices and vulnerable seniors to submit false claims and begin collecting payments they had not earned for care they had not provided.

That's changing.

First, we're paying closer attention to who is signing up in the first place. Now, before you can become a Medicare provider, you have to go through a rigorous third-party review process that will make sure you have the correct licenses and meet all the requirements to bill Medicare. The days when you could just hang a shingle and start billing Medicare are over.

Second, if criminals do get into the system, they're now a lot more likely to get caught. Starting last month, our Centers for Medicare and Medicaid Services have for the first time a comprehensive picture of Medicare claims nationwide. This means that our investigators can see billing patterns in real time and analyze those patterns. They can identify potentially fraudulent claims before they're paid, investigate them and take action quickly. And we are doing this without placing an undue burden on honest providers, allowing them to focus on providing high-quality care to Medicare beneficiaries. [Emphasis added]

Mr. Budetti makes it clear that the very system attacked as being designed for fraud has itself made it easier to spot fraud. The electronic billing system provides CMS with ongoing, real-time snapshots of its use in much the same way credit card companies use their system to spot unusual credit card usage. He contends that it works to make the entire system more efficient and it also works to highlight suspicious activity.

If the supercommittee really does want to tinker with Medicare/Medicaid, here is one area that might make sense. Make the elimination of fraud from the system a priority and back that priority up with an increase in penalties for the crime and an increase in the budget of the Department of Justice to investigate and prosecute the crime. Rooting out the criminal element from our health care system would be a lovely gift to the country.

It also would represent change we could believe in.

MediFraud

I've posted several times on Medicare/Medicaid fraud, most recently in October. Billions of dollars have been drained from these programs by unscrupulous providers, among them medical equipment providers. Too often the Justice Department is too busy with other, "more important" crimes to investigate and prosecute this fraud, but it is more willing to go forward on cases which have been put together for them. Now the DOJ and the Centers for Medicare and Medicaid Services (CMS) have some help, according to an AP report.

Staffed by elder volunteers, the Senior Medicare Patrol uses a two-pronged approach to identifying Medicare fraud.

SMP sends its volunteers to senior centers, retirement communities and elsewhere to encourage Medicare beneficiaries to guard their personal information, beware of too-good-to-be-true offers on medical equipment and carefully review their benefit statements. The patrol also collects tips on potential scams and fields calls from senior citizens who believe their Medicare accounts have been fraudulently billed.

When all they have is a whiff of something fishy, SMP participants often keep probing until they have enough information to send on to the FBI and investigators with the Centers for Medicare and Medicaid Services.

The education of elders on the issue is key. Too many elders don't realize how important their Medicare account number is, especially when combined with their social security number, date of birth, and home address. According to the AP article, an entire "phishing" industry has evolved in which an offer of free transportation to medical appointments yields that vital data, which is then sold to the next stage of scammers.

A careful review of each Medicare benefit statement would alert the elders whenever a piece of equipment or expensive medical test never received is charged. That's when the Senior Medicare Patrol steps in. The volunteers does a little probing and investigating and when there is some hard information, they turn the case over to the FBI and CMS.

The program has been successful, given the limited number of volunteers it has at this point (4,700 in the nation, with an chapter in each state). It has saved the taxpayers more than $100 million since 1997, and that could rise with a little encouragement and some funding to expand the outreach. Not a bad record for a bunch of retirees, eh?