Nobody likes fraud and every time someone is caught is is a plus. From prior posts and articles, this is more than just an effort on running algorithms as the people committing fraud are usually “better billers” as they have one focus only and don’t see patients. The link below contains a video of a sting operation from Nightline that shows how actual physical surveillance is required to catch fraud too. 
Medicare Fraud – Criminals Do a Better Job With Filing Claims And Coding Than Providers
On the automated side of the business in fighting fraud and the world of algorithms though, 1 out of every 14 claims is denied initially and some of this comes from anti fraud algorithmic mechanisms that check for certain conditions suspected to be fraud so there are false positives generated here with every carrier and company that provides this service. You might want to read up at the link below on how this happens.
How to Fight Algorithmically “Scored” Health Care Claim Denials – Line Up and Deliver Your Own Data
A we all know sometimes it is hard enough to get the benefits we are supposed to be covered for while the fraud folks roll in the money. BD
WASHINGTON, May 26 /PRNewswire-USNewswire/ -- Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and
recoveries of more than $510 million in 2009, according to data released today by the Blue Cross and Blue Shield Association (BCBSA). This represents a significant increase compared to 2008, and contributed to a three-year average return of $7 dollars for every $1 dollar spent on anti-fraud efforts.
BCBSA released the findings from its annual survey at a press briefing highlighting the Blue system's commitment to fighting healthcare fraud in an effort to save healthcare dollars and protect consumers.
"Blue Cross and Blue Shield companies are achieving significant gains in the war against healthcare fraud," said Scott P. Serota, CEO and president of BCBSA. "Blue companies are actively identifying and pursuing healthcare fraud in partnership with federal and state authorities, law enforcement, and licensing boards. These efforts protect consumers' healthcare safety and safeguard healthcare affordability. Aggressive anti-fraud investigations help ensure critical healthcare dollars are being spent appropriately."
Blue Cross and Blue Shield members can report suspected fraud through a national hotline number, 1.877.327.BLUE, and Web site (www.bcbs.com/blueresources/anti-fraud/report-fraud.html). In addition, a brochure for consumers, "One Problem. 300 Million Victims. What You Need to Know About Healthcare Fraud," is located at: www.bcbs.com/blueresources/anti-fraud/anti-fraud-consumer-brochure.pdf. An interactive Explanation of Benefits tool is located at: www.bcbs.com/blueresources/anti-fraud/explanation-of-benefits.html.
PART 1 OF 2 -- There's a neurologist who committed fraud against me by falsifying my medical records. He falsely claimed to have examined my lower extremities and falsely stated that he performed a Straight Leg Raise test and Motor Function tests on my lower extremities -- all of which he said were normal. He NEVER examined my lower extremities or performed an SLR or Motor Function tests on my lower extremities. I sat in a chair, fully clothed throughout the entire office visit both times that I saw him. The only thing he did to my lower extremities was to tap my knee caps and my ankle bones with his little reflex hammer to check the reflexes in my legs. That was it. He never felt or looked at or moved my lower extremities, nor did he have me stand or move my lower extremities other than that. The idiot even exposed the fact that he did not examine or perform tests on my lower extremities by stating "The patient says she has edema in her lower extremities." I've had chronic, severe, bilateral, pitted edema from the tops of my feet up to the middle of my thighs every single day for several years, to which at least five doctors, including two Top Doctors -- one, a vascular surgeon and the other, my internist for several years -- two venous ultrasound technicians, and family and friends can all attest. I even have photographs of the edema and discoloration in my legs -- which my internist urged me to take because of lying, do-nothing jerks like him. If this idiot had examined my lower extremities, he would have been able to say in his Physician Notes that he either did or did not see edema in my lower extremities. The fact that he said "The patient says she has edema ..." and not that I do or do not have edema is proof that he never even saw my legs, much less examined them. I suppose he was trying to imply in his notes that I was making up the edema. He stupidly didn't realize that in doing so, he was exposing himself as a liar. Thankfully, he was forced to tell the truth about some of my medical problems -- for which I had proof in MRI and nerve test reports. It was these things for which my short-term disability was approved. After the first set of forms were faxed in to the STD provider, their rep reminded me to review the second set of forms and accompanying notes before I had him fax them in to her, just to be sure they were consistent with the first set so that I would be assured of my STD being continued. That's when I discovered that he had lied "against" me in his Physician Notes. I hadn't yet opened the envelope containing the first set of forms and Physician Notes that the doctor's office had faxed to the STD provider weeks before. I never thought much about it since the STD was approved. I decided to open and read those as well. I discovered that he had told the very same lies in those Physician Notes too. I was horrified! Although his lies only hurt me, and he still recommended in the forms that I be given another 6 weeks of STD for my other medical issues -- those proven via MRI and nerve tests – I didn’t care. A lie is still a lie, and I simply did not want to be a part of it. The STD provider probably would have approved the second set of forms and given me an additional 6 weeks of STD, but now that I knew he had lied -- in effect making my condition appear LESS severe than it really was -- I was not going to knowingly show my acceptance of his lies by turning in those forms. Unfortunately, it takes months to get an appointment with a new specialist and my company was pressuring me to turn in completed STD forms and notes. While I was trying to find another specialist to see me quickly, my FMLA leave -- which was protecting my absences and my job -- ran out. Since my company's STD provider had not received updated STD forms and Physician Notes from me and my FMLA leave was all gone, my company was no longer legally obligated to keep me on their payroll; so they terminated me and my disability case was closed.
ReplyDeletePART 2 OF 2 -- That was in April of 2012, and I am still unable to work to this day. If it weren't for very generous family members coming together and helping me keep a roof over my head and pay my COBRA insurance for me, I don't know what I would do. I wrote this doctor a letter in which I gave him the benefit of the doubt -- stating that he perhaps had mixed me up with another patient and that's why he'd written so many false statements about the nonexistent examinations and tests he falsely claimed to have performed on me. I asked him to "correct" these false statements, but he refused, saying that it is against the law to change medical records after 30 days. He said he could write supplemental notes but that he would only do so if I saw him again and allowed him to examine me with a tape recorder in the room. Can't help wondering why he didn't do that all of the other times I saw him. I wasn't about to see him again for any reason. I didn't trust him, and he creeped me out too much. The worst part is, every doctor I have been to since I saw him oddly refuses to do an MRI of my lower extremities and my upper arms, whose strength has been deteriorating and in which I have much pain. I can't help wondering if his Physician Notes or something else he has said don't have something to do with that. I know that doctors access my records from BCBS, and every time they do, they are reading and believing the false statements he made about my lower extremities and upper arms. I wanted to report this fraud, but then I read a couple of bios about him online and learned that his sister is a special prosecutor with the Dept. of Justice, and he is considered a pillar of the society and is writing a book on Faith. The article said he tries to write a chapter after each church service. What a hypocrite!!! I thought, what chance have I got against this guy and what would he and his sister do to me if I do charge him with fraud. They would probably make my life a living hell. Oddly enough, the Physician Notes and completed STD forms that his nurse had previously sent me disappeared from my house. I always kept them in a folder on my desk in my living room marked Medical Records in big lettering on the outside of the folder. I've looked through every scrap of paper in my house and they are gone. I have no idea what happened to them. It gets me so mad that he will probably get away with this (1) because of his sister and his stature in the community and (2) because the only person he really hurt was me. He did not commit Medicare or Medicaid fraud, so his fraud does not affect the federal government. And, he did not do unnecessary tests or surgery on me like a cardiologist in my town went to jail for, so it does not affect my insurance company. And, since his lies made my condition sound less severe instead of more severe to the STD provider, it does not affect them in any way. So, I doubt anyone would be interested in pursuing this case anyway with me as the sole victim. I'm sure his Department-of-Justice-Special-Prosecutor sister will see to that. Guess I'll have to leave him to God to deal with. Creepo.
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