GAO: Hospitals Most Common Subjects in Civil Healthcare Fraud Investigations
Written by Molly Gamble | October 10, 2012Tags: civil fraud cases | DOJ | GAO | healthcare fraud | HHS | hospitals | investigations | Medicaid fraud | Medicare fraud | OIG
Hospitals and medical facilities made up more than one-third of the subjects in civil fraud investigations in 2010, making these facilities the most frequent type of subject, according to a new report from the U.S. Government Accountability Office.Roughly one-third of the 2,339 subjects of civil fraud investigations conducted by HHS' Office of Inspector General and the Department of Justice were hospitals and medical facilities, with the latter encompassing medical centers, clinics or practices. In 2010, 35 percent more subjects were investigated for civil fraud compared with 2005. About half of the subjects who were investigated were pursued. Of the cases pursued, 55 percent resulted in judgments or settlements.
For criminal cases, medical facilities or durable equipment suppliers made up 40 percent of the subjects. Most of the subjects were in cases that were not referred for prosecution, however. Of those that were pursued, most subjects were found guilty or pled guilty or no contest.
In total, 10,187 subjects were investigated for healthcare fraud in 2010 — 7,848 for criminal fraud and 2,339 for civil fraud.
More Articles on Hospitals and Healthcare Fraud:
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The number of investigations by both the Office of Inspector General (OIG) and of Center for Medicare Services (CMS) is going up dramatically. This is going to put pressure on hospitals to ensure all their data is fully accurate and up to date at all times. Gone are the days when estimations and suppositions for billing and documentation would work. Today and in the future, hospitals and other healthcare providers must have good systems and processes in place to ensure accurate information is being captured as care is given.
For example, a research group that produces reports on organ transplant survival rates is facing delays because of the extra work it must do to determine whether patients are still alive. The federal agency that runs Medicare uses the data to determine whether some transplant programs have such poor track records that they should be cut off from government financing.
“We are not going to be on time until this problem is corrected,” said Dr. Bertram L. Kasiske, a Minneapolis nephrologist who directs the research group, the Scientific Registry of Transplant Recipients. “It’s a big deal. A lot of people look for these reports and depend on them.”
Other medical researchers, including those conducting long-term federally financed studies of cancer and cardiovascular treatments, said the changes imposed last November were now slowing their work significantly. And a spokesman for financial industries like life insurance, banking and credit services said the change was making it more difficult to detect identity thieves who steal names and Social Security numbers from the deceased.
“There is already a consequence — there has to be — because there are fewer records available,” said Stuart Pratt, the president of the Consumer Data Industry Association.
The Social Security Death Master File is an index of 90 million deaths that have been reported to the agency over 75 years by survivors, hospitals, funeral homes and state offices. The listings include names, Social Security numbers and dates of death.
The agency did not make the information public until 1980, after a legal ruling required that the data be disclosed. The list is updated weekly, and although it is neither comprehensive nor 100 percent accurate, it is considered the most current record of deaths nationwide, making it a rich trove for researchers.
It is also far more affordable for researchers than the leading alternative, a death index kept by the federal Centers for Disease Control and Prevention that, while more complete, is typically 14 months to 18 months out of date.
For a decade, the Social Security master file routinely included records provided by the states. But last year, after reports that the widespread availability of death records was facilitating identity theft, the Social Security Administration determined that it had been improperly releasing the state records as part of the file.
Under a 1983 law, the agency concluded, those state records — but only those records — were exempted from public disclosure. They could, however, be made available to other federal agencies, like the Internal Revenue Service and the Centers for Medicare and Medicaid Services, that needed them to determine whether to pay or discontinue benefits.
As a result, four million deaths were expunged from the publicly available master file last November. Social Security officials expect the number of deaths disclosed each year — 2.8 million were made public in 2010 — to decrease by one million.
For epidemiologists, it can be critical to learn quickly when the subject of a study has died so that details can be gathered while memories and records are fresh. Without an updated national index, it can be difficult to track those who have moved repeatedly or perhaps died alone.
Jesse D. Schold, a health researcher at the Cleveland Clinic, said the holes in the master file, which will only grow larger, had already compromised his investigation into mortality rates among living kidney donors.
Confirming deaths of subjects by surveying every state would be prohibitively burdensome, he said. And using the index compiled by the C.D.C., which pays states to submit refined data, would be unaffordable, costing perhaps $30,000 to $50,000 a year.
By contrast, an annual subscription to the Social Security file, with unlimited searches, can be bought for as little as $995. Genealogy Web sites make the data available on the Internet at little or no cost.
“It’s very critical that we have an objective way to measure deaths,” Dr. Schold said. “Otherwise we’re getting the data from the centers we’re measuring, and that’s problematic” because they cannot track all former patients until death.
Gary Chase, the senior project manager of the Nurses’ Health Study, a 36-year Harvard examination of cancer prevalence among more than 200,000 women, said the new policy had “thrown us back to the pre-Internet era, where you’d start looking in the phone book for someone with a similar name and sending out a bunch of letters.”
Greta Lee Splansky, the director of operations for the Framingham Heart Study, which is based at Boston University, said the withheld records meant “the loss of a very valuable tool.”
Over six decades, the study has examined the causes and effects of heart disease in three generations of subjects who were originally from the same town in Massachusetts. Many are dying off. “It just slows us down,” Ms. Splansky said. “It’s wasting research dollars.”
Mark Hinkle, a spokesman for the Social Security Administration, said researchers would simply have to collect the data from the states.
“I don’t want to sound offensive,” Mr. Hinkle said, “but our job is to administer the Social Security program, and administering a death list really isn’t in our core set of workloads. The bottom line is that we have to follow the laws and administer the programs we’re supposed to administer.”
In response to pressure from panicked medical researchers, the C.D.C. hopes to start updating its death index more quickly, but it will not be able to reduce the cost, said Charles J. Rothwell, the director of vital statistics.
Federal agencies with a stake in medical research have been lobbying Social Security officials to consider a compromise.
In Congress, concerns about identity theft — some driven by tax fraud cases involving deceased children — have prompted proposals to restrict access even further.
Representative Sam Johnson, Republican of Texas, has introduced legislation to end the public disclosure of the master file altogether. Senator Bill Nelson, Democrat of Florida, has proposed a bill that would keep death records private until three years after a person died.
Mr. Johnson seems unmoved by the researchers’ plight or by the argument that his bill would hobble the detection of consumer fraud even as it seeks to disarm the thieves.
“The decades-old practice of publishing personal death information that anyone can buy needs to end,” he said, “and now.”
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Crash diets don't work.
They don't work for losing weight, they don't work for making sales quota and they don't work for getting and keeping a job.
The reason they don't work has nothing to do with what's on the list of things to be done (or consumed). No, the reason they don't work is that they don't change habits, and habits are where our lives and careers and bodies are made.
If you want to get in shape, don't sign up for fancy diet this or Crossthat the other thing. No, the way to get in shape is to go to the gym every single day, change your clothes and take a shower. If you can do that every single day for a month, pretty soon you'll start doing something while you're there...
If you want to make sales quota, get in the habit of making more sales calls, learning more about your market and generally showing up. If you show up, with right intent, you'll start making sales. The secret isn't a great new pitch or a new pair of shoes. The secret is showing up.
Your audacious life goals are fabulous. We're proud of you for having them. But it's possible that those goals are designed to distract you from the thing that's really frightening you--the shift in daily habits that would mean a re-invention of how you see yourself.
Organizations can always benefit from better habits. Every day. Do that first.
I couldn't have said this any better myself. Great work comes from great, everyday, all the time HABITS. It does not come from bursts of work here and there. This goes for every corner, every position of Mobile Aspects. Specifically, Seth Godin gives the example of the sales person who should show up every day with the right intent, every day.
This works for every part and every one in our company. In everything you do, develop great habits that you will do all the time. Great habits lead to great work.
The article from kevinmd.com (a favorite site of mine) below raised a great question: what is the definition of innovation? The article mentions the DaVinci robot used in surgery in hospitals, but is that really innovation? The author says, not really, it is just a fancy way to perform surgery and doesn't necessarily lead to better outcomes (I am not against the DaVinci robot - in fact, we studied the science behind it extensively during my undergrad Biomedical Engineering days at Johns Hopkins).
So back to the question - what is innovation? A lot of people think innovation has to be flashy. It doesn't! An innovation can be as simple as a checklist - a major tool being touted by Dr. Atul Gawande for delivering safer care with much less preventable errors. You could throw a checklist into software, but the software isn't the innovation; it's still the checklist.
In my mind, innovation is a simple tool, or an idea, to deliver a better outcome. That outcome is defined by the marketplace and the user. In healthcare, today, in typically means lower costs, safer care and easier user.
That's what we focus on at Mobile Aspects - helping hospitals deliver care through a simpler workflow and having rich, accurate data. Though everyone looks at our best of breed RFID technology as the innovation, it's actually just the vehicle. Our CTO (Timur Sriharto) and all our engineers are innovators because they work closely with our customers. They see the problems they have on a daily basis in hospital surgery and help them find easier ways to deliver care.
For example, many systems in healthcare want users to login with a text ID and password; some even use biometrics. Our team immediately saw that this is difficult in surgery - caregivers are wearing gloves which can make data entry difficult and the powder from gloves makes biometric thumbprint difficult. While other companies tried to enhance biometric sign in, our team said forget it! We were the first to say - 'You already have an ID card, we'll just use that to login.' There are actually more challenges to this than you would think, but our customers were excited by this simple idea, so we ran after it. Now in our systems, users don't touch a keyboard once, or do any data entry with their fingers- its simplicity in the design that makes our systems so effective and reliable.
That's innovation - a simple tool or idea that brings a better outcome to the end market and user. It can be packaged many ways, but it doesn't need to be more or flashier than that.
In Medicine, Falling for Fake Innovation
A great article by the New York Times on what happens when doctors and clinicians begin thinking about costs of care. As was 25 years ago, today, many clinicians still dont know the costs of items and service. OK... they know whether something is "expensive" or "not expensive", but they generally dont have any further granularity then that.
I dont want my doctor, or any doctor, making decision solely on the cost of items. However, to make decisions completely without knowing the costs? In the end, it actually hurts care... money that could have been spent on another patient is wasted on a different patient because costs were not known. Cost is ONE attribute in delivering care, not the attribute.
We all want what is best for patients across the healthcare spectrum. Its time we start giving hospitals and clinicians more insight into the costs of care. Clinicians can still deliver care optimally, but by knowing the costs, they can determine if something cheaper, but just as effective, could replace it. Overall, this increased the quality of care by leaving dollars on the table to spend on another patient who may need it.
