This story about Walgreens illustrates a little bit of both. After the economy and Wall Street news of the last couple of weeks, we should know now about how programmers set algorithms to select, process and deliver data. Need a refresher, you can check here relative to Wall Street out coding the government and us by lying to their computers. 
There were 4 states having an exception on their payment formula and it appears those changes may not have been programmed in place, which would fall under the IT/IS directors area of Walgreens for compliance there. We already know the government is still working on their algorithms as fast as they can when stories such as claims being paid to “dead doctors” come up, and not only create areas of shortfall or fraud, but embarrassment as well, so again a little cross reference left out to see if the doctor was still alive and an active provider; no word yet if there were any dead patients found in the same investigation, which could be the next algorithm or SQL process to be checked.
Whistleblowers: These folks work with the processes in the field day in and day out, thus just like a beta tester for software, they are more apt to be aware of problems, such as the ones in this case who will profit due to finding and reporting the errors, so in essence in some areas whistleblowers can be just like real expensive beta testers! Who found the errors, the pharmacists, so I rest my case here. 
In the case of data not being matched, it could be worthwhile maybe to find some beta testers that might work a little cheaper than those that start at a million and go up. (grin). I am guessing here the Department of Justice was able to perhaps find some billing examples and perhaps had access to running some balance sheets to find the errors, and they too can be expensive when it comes to correcting the formulas that substantiate the amount of payment, and fines too! This cost everyone all the way around here. BD
Walgreen has agreed to pay $9.9 million to settle allegations by the Department of Justice and four states -- Florida, Massachusetts, Michigan and Minnesota -- that the company improperly billed Medicaid, DOJ said in a statement on Monday, the Miami Herald reports (Miami Herald, 9/30).
In those four states, Walgreen can bill Medicaid programs only for the amount of copayments for medications dispensed to beneficiaries who also have private health insurance, DOJ said. DOJ did not disclose whether Walgreen admitted any wrongdoing as part of the settlement (Miami Herald, 9/30).
The allegations against Walgreen resulted from a whistle-blower lawsuit filed by Daniel Bieurance and Neil Thompson, two pharmacists in Minneapolis. Under the settlement, the pharmacists will receive a combined $1.44 million.
I worked in IT at Walgreens corporate HQ for a time. Back then, their systems were pretty primitive, possibly because the head of IT (aka big cost center) reported to the CFO. Case in point - standard desktop systems ran DOS-based software (Lotus 123 v2.x, Q&A 4 and Attachmate or IRMA for 3270 emulation) until Y2K.
ReplyDelete"when claims being paid to “dead doctors” come up..."
ReplyDeleteAs an EMR/POMIS vendor, I can tell you that customers repeatedy and frequently ask for automated systems that "know" which supervising physician was on duty at that time. Usually, though, they want to input the doctor's "typical" schedule and don't think about what they'll do if he's not there.
My company always resisted the cries for these products because we figured it would lead to fraud. "Dr. Jim was out sick on Monday, and yet he was still the supervising physician on a hundred medical procedures." The customer isn't actually committing "fraud" per-se, they're just being sloppy with reporting their data. Joe was on duty covering, but Jim was REPORTED to be on duty.
It's hard to admit wrongdoing in that sort of situation, because it's clear that most clients don't have any criminal intent.
Still, it is good to know that the moral high ground would be appreciated one day.
Yes I have seen that in physician's offices and yes there is no real intent to defraud anyone as it's just a matter of quick data input and getting the job done.
ReplyDeleteRight now the frustrating part is more so with the government, as those who were creating a case of fraud knew good and well they were submitting under a dead doctor's name and we need the data systems to cross reference and find those folks before it grows higher, an embarrassment to CMS for sure.
The government puts out policies and procedures and yet at times their own internal data systems are not up to date to handle the pre-requisites they established.
The government could use some help with algorithms.