Dr. Barry Johnson discusses the importance of mobilizing providers, payors and members in the fight against health care fraud.
Clinical Director, Dr. Jeffrey Davee, explains how creating a clinical panel can empower your organization to collectively fight fraud.
Former Hospital CFO, James Alderson, recounts his industrychanging 13 year struggle for justice after blowing the whistle on fraudulent health care giants.
Health Care Market Facts & Fraud Statistics – A closer look at what’s really going on. Finding Shark Teeth – An Analyst’s account of what to look for when investigating health care claims. Health Care Reform – Learn what the Administration is doing to change health care. The Profiler Interview – Meet the Chief Operating Officer of HealthCare Insight, Joel Portice.
The Oven – Learn what’s cooking in Sales and Marketing as Darin Johnson presents the “Do’s and Dont’s” of social media campaigns.
A Thief’s New Treasure – Find out how to protect yourself from medical identity theft.
Letter From the Editor – Profiler’s Editor-In-Chief discusses the focus of this issue.
Note to Self – Profiler picks the best books, websites, blogs and web apps you need to check out.
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I’ve been in the business of detecting health care fraud, abuse and overpayment for nearly a decade. During that time, I’ve seen and heard health plan executives and industry professionals discount the prevalence and scale of the fraud problem, while others have dismissed the issue entirely. I’ve read, shared and published countless articles, white papers, market stats, press releases and other documents promoting fraud awareness and challenging payors to take action. Has the message finally stuck? We’ve come a long way since Malcolm Sparrow published License to Steal: How Fraud Bleeds America’s Health Care System in 2000. Health care reform is front and center on the national stage and the issue of fraud prevention has a leading role. During the White House Forum on Health Reform in March of this year, President Obama stated, “We can agree that if we want to bring down skyrocketing costs, we’ll need to modernize our system and invest in prevention. If we want greater accountability and responsibility, we must ensure that people aren’t overcharged for prescription drugs or discriminated against for pre-existing conditions. We need to eliminate fraud, waste and abuse in government programs.” In today’s difficult economic environment, private sector health care payors are beginning to understand the scale of our fraud problem and the need to address it. What’s not understood is how best to fight it. By 2013, annual health
care costs are set to eclipse $3 trillion, and potential fraud losses could surpass $1,000 per capita. It’s time for consumers to also understand how fraud impacts them and get involved in the fight. Each individual can make a difference in the fight to stop fraud and offset the billions wasted each year. In this issue of Profiler Magazine, Dr. Barry Johnson proposes the notion that payors must move to mobilize a free and untapped fraud-detection task force. By reading the story of James Alderson, we’re reminded that one man can make a difference and influence the course of medical reimbursement in America. From Dr. Jeffery Davee, we learn how several clinical heads are better than one when taking on dishonest providers. For your educational enjoyment, we’ve included our usual list of Profiler’s Best, market cost statistics, and tips on how to leverage social media to give your brand new life. You’ll also find interesting articles regarding medical identity theft prevention and how finding fraud is like searching for shark teeth buried in the sand. Profiler Magazine is published on a semi-annual basis, so look for another issue to come across your desk during spring of 2010. In the meantime, keep up on the latest in health fraud by visiting us online at www.profilermag.com or share your thoughts with us by emailing darin@profilermag.com.
Toll Free: 877.619.5557 Fax: 801.285.5801
PUBLISHER HealthCare Insight info@hcinsight.com
EDITOR IN CHIEF Darin Johnson darin@profilermag.com
SENIOR EDITOR Deborah Evans deborah@profilermag.com
ART DIRECTOR Mica Johnson mica@profilermag.com
ASSOCIATE EDITOR Shane Sanders shane@profilermag.com
CONTRIBUTORS Barry Johnson Joel Portice Jeffrey Davee Michelle Higginson
WEBSITE www.profilermag.com Copyright © 2009 by Profiler Magazine All rights reserved. Materials may not be reproduced in whole or in part without written permission. For reprints of any article, contact the editor. *The opinions expressed by any contributors are not necessarily those of Profiler Magazine.
“Dwell in Possibility” –
Art Director
my personal motto for
A buddy of mine in the art
many years. I believe living
department back in college
in the moment and always
had this phrase tatooed on
"The heights by great men reached and kept, were not obtained by sudden flight. But they, while their companions slept, were toiling upward in the night."
keeping an open mind are
the inside of his arm just
- Henry Wadsworth Longfellow
movies. It makes you really
the keys to a happy life.
above his right elbow. I
Several years ago while
think about the universe
Sure, my ‘never say never’
don’t know if he made it up
working full-time during the
and our place in it. What
attitude gets me into some
himself or if the quote came
day, attending business
the human race has
trouble at times, but I’d
from someone else, but I’ve
school at night and
achieved, what we are
much rather exist in this
always really liked it. To me
planning a wedding, I was
capable of, and also just
world accepting that
it’s sort of a call for
starting to burn out. One
how small we are in the
ANYTHING is possible.
everyone to throw a little bit
afternoon over lunch with
grand scheme of things. It’s
of change and diversity out
my mother, she handed me
something that helps me
into the world, and to give
a small laminated card and
analyze all aspects of my
more of themselves. I could
told me to carry this in my
life and to truly appreciate
be totally wrong though,
wallet and encouraged me
the paths I take on this
and it could just be a joke.
to “stick with it.” I turned
great journey through the
Either way it’s good.
the card over and read this
cosmos.
Emily Dickinson
“What a difference a little difference would make.” - Anonymous
Shane Sanders
Associate Editor
Darin Johnson
Editor in Chief
Mica Johnson
Senior Editor
Deborah Evans
This simple quote has been
quote by Longfellow. I still carry the card to this day.
“If it is just us, seems like an awful waste of space.” - Jodie Foster in “Contact”
This quote is my favorite line from one of my favorite
“Undercover” is the true story of John Schilling, a mid-level accountant, who unexpectedly became the catalyst for a string of 'whistleblower' cases that disrupted the health care industry in the late 1990s. When he unwittingly discovered that the Columbia Hospital Corporation was siphoning billions of dollars away from Medicare and stealing from American taxpayers, he spoke up for what he believed to be right. "Undercover" tells of Schilling's incredible journey from average citizen to federal informant. To learn more about the Schilling case, read The Man Who Made a Difference: The James Alderson Story in this issue of Profiler.
Written with the wit, wisdom and contrarian opinions Kawasaki is known for, “Reality Check” teaches readers how to ignore fads while sticking to reasonable practices. Learn about such topics as: How to get a standing ovation; the art of schmoozing; how to create a community; and the top ten lies of entrepreneurs. From competition to customer service, innovation to marketing, this useful guide to business will become a staple in your library. Irreverent, edgy and engaging, Kawasaki’s sense of humor really comes through in this one.
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$8,459
2010
$2.62
2010
$8,851
2011
$2.77
2011
$9,767
$9,282
2012
$2.93
2012
2013
$3.11
2013
*Not all cost categories are represented in the above displays.
ning to make a significant impact on Medicare costs, while Medicaid spending growth continues to accelerate. “Average annual spending growth by public payors (7.2 percent) is expected to outpace that of private payers (5.3 percent) through 2018. As a result, the public share of total NHE is expected to exceed 50 percent by 2016 and reach 51.3 percent by 2018.” While annual growth rates are projected to continue trending upward, the need for payor-centric cost containment solutions and administrative efficiencies will also continue to rise. Supporting this notion, the Obama administration has pledged to reform health care by improving administrative workflow, reducing costs and providing coverage for all Americans. Regardless of what happens with the nation’s health care system one thing remains certain: Obama and his team certainly have their work cut out for them.
$10,318
2014
$3.31
2014
% of Gross Domestic Product
Amount Per Capita
According to the National Health Expenditure (NHE) report released this year by the Center for Medicaid and Medicare Services (CMS), annual NHE growth is expected to increase by an average of over 6 percent annually through 2018. Annual health care costs are projected to surpass $3 trillion by 2013, showing a slight decrease from 2008 NHE figures, which projected reaching the $3 trillion mark by 2012. The CMS report stated that the “recession is anticipated to cause divergent trends in health spending growth for private and public payers in 2009. Private health spending growth is projected to decelerate from 5.8 percent in 2007 to a 15-year low of 3.9 percent by 2009, driven by excepted slower income growth and declining private health insurance coverage rates.“ The slower growth figure is encouraging, but mitigated by the reality of rising costs in the public sector. According to the report, the Baby Boomer generation is begin-
$10,929
$11,598
2015
17.7%
2010
$12,325
2016
17.9%
2011
2017
18.0%
2012
18.2%
2013
$13,100
2018
18.5%
2014
4
Alderson, a Montana native, began his accounting career upon graduating from MSU in 1969. After opening a practice and working for many years in Whitefish, a small ski town in northwest Montana, Alderson accepted a full time financial officer position with North Valley Hospital. Over the next six years, Alderson handled the hospital’s affairs and climbed the ladder to Chief Financial Officer. But in 1990, everything changed when North Valley’s top administrator moved on and the hospital board decided to turn to a management company to run their operations. Quorum Health Resources Inc., formerly a division of Hospital Corporation of America (HCA), impressed the board with claims that they would be able to obtain maximum reimbursement for hospital expenses filed with the federal government through the cost reporting system. In the summer of 1990, Quorum was selected to run North Valley - a decision that would forever change James Alderson’s life. Alderson stayed on with North Valley and retained his position as hospital CFO, working directly with the new management firm. In late September of 1990, two months after Quorum assumed management, Alderson recalls a meeting in which a district vice president of Quorum asked Alderson if he was familiar with the practice of preparing two cost reports, spreadsheets containing reimbursement amounts from state and federal Medicaid and Medicare divisions. When he questioned why two reports would be prepared, he was told that it was Quorum’s procedure to keep two sets of records for reporting health care costs for Medicaid and Medicare patients – the first being an aggressively inflated ledger sent to the federal government for reimbursement, and another conservative report of hospital operations for internal use. The difference in costs between the two reports was kept in a reserve account. If the aggressive claim sent to the government survived the standard two-year period in which an audit could occur, the hospital could book the reserve funds as
revenue, significantly improving annual profit margins. Alderson was shocked by what he heard and told the district vice president that he never did two tax returns for anyone as an accountant and he wasn’t going to do two cost reports. The district vice president departed the room without much further comment. A few days following the conversation, Alderson was on a Quorum manager’s retreat to Alaska. According to Alderson, during breakfast on Sunday morning, the same district vice president told him he was being dismissed. Alderson wasn’t offered a reason for his termination, other than the fact that the arrangement just wasn’t working out. Unable to find other work in Whitefish, Alderson took a financial job with a small hospital in the rural town of Dillon, Montana, where he and his family had trouble adjusting. Alderson became angrier the more he thought about what had happened in Whitefish. He was sure he had been forced out of North Valley because of his refusal to keep two sets of financial records. Worse still, he realized that Quorum used accounting handbooks of its former parent, HCA. Alderson figured if Quorum manipulated cost reports, HCA must as well. In May 1991, Alderson filed a wrongful termination lawsuit and demanded copies of Quorum’s reserve reports and related records.
The documents he received backed up his worst fears. Alderson’s accusations of wrong doing outraged hospital lawyers, who denied breaking any laws. But Alderson, still feeling that he was on to something, decided to phone North Valley hospital’s former administrator. After hearing what Quorum was doing, the ex-administrator told Alderson about a case he had recently heard about called a qui tam, which allowed private citizens to file a lawsuit on behalf of the government for false claims or fraud. Alderson had never heard of qui tam cases but resolved to learn everything he could about filing one. Investigation became a second job as he spent nights and weekends reviewing hospital documents and exhausting his personal time traveling to the University of Montana law library in Missoula, researching everything he could find to support his case. In December 1992, Alderson completed his qui tam lawsuit draft, which included charging four huge hospital companies with fraud. Through his research, Alderson had learned that unlike most other lawsuits, a complaint under the False Claims Act must be served on the government but must not be served on the defendant until ordered by the court. It must also be filed under seal. By filing the suit, Alderson and his family were sworn to secrecy, barring them from discussing the case with
James Alderson at his home.
anyone, including friends and extended family members. Alderson knew that after filing his complaint and providing all necessary documents, the government had 60 days to intervene, decline to intervene, move for an extension of time to determine whether to intervene, seek dismissal of the action, or settle the case. “I thought that asking for 60 days of your life wasn’t any big deal.” Alderson said. But he was about to learn that it would be a very long 60 days. Days turned into months as federal lawyers and investigators requested numerous extensions. By late 1995, the case had stretched on almost three years. The other three defendants besides Quorum had been purchased by Columbia Healthcare Corporation (creating Columbia/HCA), and Alderson was losing hope. But as fate would have it, Alderson came across the name of Steven Meagher, a former Federal prosecutor who worked with the San Francisco office of Phillips & Cohen, a law firm that specialized in qui tam suits. Alderson promptly flew to California to tell his story to Meagher and his colleagues. Upon seeing how prepared and relentless Alderson was, Meagher accepted the case, giving Alderson a chance to salvage years of effort. In the summer of 1996, Meagher began breathing new life into the case by moving it from Montana to
Florida and contacting an agent with the Federal Bureau of Investigation. Based on information from Meagher, the FBI began a criminal investigation of cost reporting fraud by Quorum and Columbia/HCA. In late 1996, a huge break in the case occurred when John Schilling, a former Columbia/HCA CPA, came forward with evidence for a lawsuit similar to Alderson’s. Schilling proposed that his complaint be combined with Alderson’s in order to strengthen the case, which Meagher accepted. In the spring of 1997, Schilling went back to work as a consultant for Columbia/HCA while wearing a wire for the FBI and covertly mapped out Columbia offices. The FBI made their move in July of 1997 by raiding 35 Columbia hospitals in 7 states, searching for evidence of illegal accounting practices. Weeks later, 200 Columbia/HCA hospitals in 37 states were added as defendants in the qui tam lawsuit and three Columbia executives were indicted for cost reporting fraud. But despite such developments, the government still didn’t take on the case. Sixty days had become five years and counting, leaving Alderson to wonder if the seal would ever be lifted. In the autumn of 1998, the government asked for more time. Tired of keeping his involvement in the proceedings secret from friends,
colleagues and extended family, Alderson said he wouldn’t agree to any further extensions. Unable to stall any longer, the government finally informed him that they would formally intervene in the case on October 5, 1998. Alderson’s tenacity, along with the undercover effort of Schilling, resulted in the largest government fraud settlement ever negotiated by the Justice Department. In 2001, Quorum settled with the government for $85.7 million and the judge awarded Alderson 24 percent of the recovery. In 2003, Columbia/HCA Healthcare Corporation paid $631 million to settle three separate qui tam lawsuits, including the Alderson/Schilling case. Both men shared a $100 million award for their efforts and the work of their attorneys on the case. Disappointingly, the criminal convictions of the three indicted Columbia executives were later reversed on appeal so no one served time for the crime. Since 2003, thousands of whistleblower suits have been filed, netting billions in recovered money for the government, and rewarding whistleblowers themselves (and their lawyers) with millions. The Alderson’s have generously contributed some of their settlement funds to the MSU College of Business and a new aquatics center in Whitefish. Now retired from health care and a grandfather of four, Alderson says, “I am not bitter toward anybody. This was a fight over business practices. I said from the beginning that I would quit whenever someone could show me that I was wrong. In thirteen years, they never did.” Alderson is happy to see improvements in the health care industry due to his determination to make a difference. Bonus systems have changed, discouraging the motivation for employees to cheat and Medicare spending costs have been drastically reduced since his case exposed the fraudulent practice. As Alderson says, “It feels good to have been a big part of this change.” He believes the majority of providers are honest and have nothing to fear, but warns “the minorities who are dishonest should fear the False Claims Act.”
T
olstoy once said, “Laws are rules made by people who govern by means of organized violence, for noncompliance with which the noncomplier is subjected to loss of liberty…” Refusal to recognize and confront the health care fraud problem is endangering the credibility of health care leaders and is jeopardizing our future rights to responsibly regulate our industry. Joint cooperation among all parties to detect, report and reduce fraud, abuse and overpayment could revamp the entire health care system, significantly improving the welfare of each and every American for years to come. The power of one is a mighty start, but the power of all is a force that cannot be ignored. It’s time for everyone to step up and get involved. We are currently experiencing the convergence of economic, political, social, legislative and legal interests — each with varying motivations, but all with the common objective of changing the nature of how we access, deliver and manage the costs of health care in the United States. Whether the U.S. health care system is squandering $70 billion or $255 billion a year on
fraud, waste, abuse, payment optimization schemes, or general misuse of health care dollars, we can no longer discount the issue or the associated collateral problems it causes. Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association, made a significant observation during a recent address at a property and casualty fraud conference. He stated that one of the challenges of fraud prevention in our health care system is that the very payors who must undertake the prevention initiatives view perpetrating providers as part of their essential delivery system. That means any sanctions or penalties to a provider potentially compromise his or her ability to offer services to the contracted patient population. This dual role — to provide adequate patient access to providers and also bear the responsibility as guarantor of honest and accurate claims processing — results in a widely divergent interpretation and execution of each role by payors. Providers, payors and patients must commit to identifying the small percentage of abusive providers by taking necessary actions to eliminate opportunities to rob the health
care system and run up costs. It’s an opportune time in the history of our industry to comply with waste prevention mandates and evolve beyond initiatives that detect but do not deter or punish the perpetrators, whether they are dabbling opportunists or organized fraud rings. Politicians as divergent in philosophies as President Obama and Newt Gingrich are calling the public’s attention to the magnitude of health care fraud and are suggesting the prevention of this waste be used as a means for providing coverage to numerous uninsured citizens. An essential part of the President’s stimulus proposal is the implementation of targeted initiatives to prevent fraud that is currently driving up costs and putting patients at risk by subjecting them to unnecessary
tests or therapies to increase provider revenues. More transparency in all aspects of health care cost and quality management is also an emerging focus. The concept of a consumer-driven system in which patients have more access to information that enables them to make better choices in understanding services, qualifications of providers and fair fees is being fueled by legislative, executive and judicial branches of both state and federal governments. We see state attorneys general, congressmen and even judges weighing in on behalf of consumer interests. The Office of the Attorney General of New York State, headed by Andrew Cuomo, investigated consumer complaints and concluded that the health care industry was systematically manipulating UCR (usual, customary and reasonable) fee calculations, thereby transferring a disproportionate amount of the burden to pay out-of-network fees from industry payors to the consumer. The resulting settlements will transfer the responsibility of determining and publishing those fees from the industry to a neutral not-for-profit third party that will publish medical fee information, making it available
to payors, providers and consumers. In 2009, for the first time in history, we can expect all consumers, providers and payors to have access to the same geographically and specialty-specific medical services pricing information. There are already many free information sources as well as some fee-based services where consumers can review the credentials and qualifications of medical providers. For the knowledgeable consumer, public records and websites are also available to determine if recorded sanctions exist on provider licenses. Furthermore, consumers can access information on hospitals to examine quality measures of the facilities they plan to use. With emphasis on the elimination of fraud and a focus on consumers as part of the solution, it is reasonable to expect that consumers will demand information on providers who abusively and fraudulently bill for services. With health care fraud receiving so much attention, will everyone finally step up and do something? Will the health care industry proactively clean its own house rather than waiting for external forces to impose mandates to do so? Will we own up to the fact
that a small percentage of providers are wasting billions of dollars annually and exposing patients to unnecessary risks for personal gain? Will we have the courage to lead the fight against this small minority of providers, irrespective of network and political affiliations? Will we take advantage of the new tools and services that can rid the system of rampant fraud and abuse? Will we enlist the help of our insured members, and will we provide them the tools to help identify and prevent fraud perpetrated by the providers who treat them? Will we stop frustrating patients who identify suspected problems with their bills by actually encouraging them to explain the anomalies and then undertake appropriate investigations and recovery? As an industry, let’s not lose our right of self-governance. Instead, let us deliberately choose to be proactive. Whether you’re a provider, a payor, or a consumer, we all need to do something and do it now. This is the time for change. Choose to be a leader — an innovator — and do the right thing before we are all forced by government mandates and regulations to take unfavorable actions.
Improve Explanation of Benefit (EOB) documents by listing every line of service, including the procedure code and the real service description (not just “medical service”), along with the amounts billed, allowed, paid, and the remaining patient responsibility. Provide customer support services to teach insured members how to read and interpret EOB forms. Provide a telephone hotline or web portal to plan members so they may ask questions about services received. Provide convenient sources for members to report suspect billing practices or questionable behavior on the part of the providers who treat them. For example, if a member sees an EOB line item for an office visit that involved complex decision making and 30 minutes of face-to-face time with the provider, but they know they spent less than five minutes being diagnosed by a physician assistant, they could enter their complaint on a payor-provided website. Encourage covered members to visit sites like www.StopHealthCareFraud.com to seek out more information on how they can identify and report suspected fraud.
Advise members against providing their insurance card or personal information to any door-to-door or telephone solicitor offering free services that can “be billed to your insurance company.”
Teach members how to report loss of medical identification cards immediately.
Provide members with access to all credentials of providers on the PPO panels that the payor contracts with or owns. Instruct members to go to other appropriate sites and sources to investigate out-of-network providers they may be referred to.
Educate members how to get more than one opinion if they are referred to a provider who recommends treatment, tests, or services that seem unreasonable.
Encourage members to purchase health care services with the same care and evaluation processes that they use to buy other services and products. This includes stopping at the front desk on the way out of the treatment area and asking about the services, tests, or x-rays they received that day and the associated costs. This also includes asking the provider what services they are recommending and the approximate fees associated with those services prior to delivery or referral to receive them.
Continually reinforce members’ obligation to be wise and judicious consumers of health care services and help them understand that waste does not only impact the insurer’s costs, but it ultimately drives up member premiums and out-of-pocket costs for services.
18
O n my desk is a small collection of shark teeth I’ve collected from my favorite beach. They not only serve as a reminder of a treasured vacation pastime, but also as a symbol of the work I do as a registered nurse clinical analyst, reviewing claims and medical records to identify billing errors and fraud. Like hunting for shark teeth, identifying fraudulent billing patterns is a matter of not only knowing where to look, but what precisely to look for. Shark teeth are not usually found lying in plain sight on top of the sand; they are partially buried and vary in size, shape and color. Just as the teeth differ in appearance, health care fraud can be concealed in many forms, including upcoding by providers, submittal of false claims by organized crime rings and medical identity theft. False reporting of medical services to receive monetary or other benefits is a rapidly growing and constantly fluctuating crime. Perpetrators of medical fraud are typically quick to change billing schemes and locations, always trying to stay one step ahead of investigators. They attempt to make their claims blend in with those of honest providers in order to avoid edits and audits. As teeth on the beach are evidence of sharks in the water, suspect claims are evidence of fraudulent billers, actively seeking easy prey. Inadequate fraud control is like blood in the water, attracting both the unscrupulous provider and the hardened criminal. An effective fraud control program capable of identifying criminal practices must include human review of all suspect claims, since even the best computer programs are unable to match the pattern recognition capabilities of the human brain. Claims processors can be trained
and software can be programmed to identify and flag certain obvious types of billing inconsistencies. But with billions of dollars lost to fraud every year, those methods are not enough. It takes a clinical expert to find fraud; one who is trained to scrutinize claims and medical records for anything that seems out of place. Recognizing fraudulent billing patterns requires looking beyond the obvious to find the anomalous. Expert review of claims prior to payment creates significant savings as less obvious fraud and errors are identified and incorrect payment is prevented. There are indeed greater costs associated with paying a clinical expert to review claims, but those costs are mitigated through greater claims review efficiency and payment accuracy. Clinicians know what is typically included in surgeries and procedures, the usual dosage of medications for different conditions, what supplies are necessary, the types of services performed by different provider specialties and how often particular services should be carried out. They can look at clinical notes and decipher the abbreviations and handwriting, applying years of clinical experience and training to the review process. With an effective clinical review program in place, suspect patterns can be identified with greater efficiency and accuracy. Just like recognizing a shark tooth among shells in the sand, abusive schemes can be removed from the sea of claims and acted on before payment is sent to a potentially fraudulent biller, preventing a feeding frenzy on private and public health care dollars.
National Health Care Anti-Fraud Association
Mark your calendar now!
2009
Annual Training Conference & Anti-Fraud Expo
NOVEMBER 17–20, 2009 Rosen Shingle Creek Orlando, Florida
Visit www.nhcaa.org/ATC for the complete conference schedule.
Consequently,
administration processes undertaken by health care payors, performed with a high level of technical expertise, can provide some degree of insulation and protection to payors held to meeting costcontainment requirements. As a board certified oral and maxillofacial surgeon, I have learned firsthand how collaborative discussions among experts can be very beneficial to a patient’s quality of care while minimizing expenses. Some time ago, several years into my dental practice, I was serving as an active member of a hospital staff in California where I accepted emergency calls for major maxillofacial trauma. One night I was called to the emergency room to treat seemingly unrepairable facial injuries to a worldrenowned actor. Upon arrival, I was barely able to identify the face that I knew from television and the big screen. Because of the actor’s prominence and the diagnosis of multiple injuries, the situation clearly required a team approach. A panel including myself, physicians, and nurses from
cardiology, anesthesia, radiology and general surgery was promptly assembled to chart the actor’s immediate needs and prioritize his treatment. Knowing that I was handling a patient who made his living with his face created incredible pressure for me, which was exacerbated by the national media attention of the case. Our teambased treatment approach was successful due to the group effort from the professional panel of clinicians involved, who were all thanked by the patient on national television. Years later, I am now a clinical director for a company in the health care industry that utilizes a clinical panel approach in preventing medical and dental fraud, abuse and overpayment. It is remarkable that the same concept of an expert clinical panel is just as essential in this field as it is to practicing surgeons and other medical and dental care providers. From a purely claim review approach, coding experts with clinical experience, utilizing state-ofthe-art detection software, can provide the analysis needed to pay claims
accurately and combat fraud. If reviews are performed by clinicians with a coding background, a payor can be reasonably certain that overpayments will be prevented with a higher degree of medical interpretation. Additionally, in situations when a provider might deliberately misrepresent codes and services, the knowledge and experience of a clinician would be invaluable in pursuing the provider from a fraud perspective. With many payors already resource constrained, assembling a clinical panel for the sake of claim review must be done carefully to ensure clinical and technical expertise in specific areas of medicine and dentistry. Experts should be selected by location, as many states require reviews on claims originating in their states to be reviewed only by a provider licensed in that state. Additionally, panel members should have active licensure and board certifications for specialty claims and cases. Members of the clinical panel should be knowledgeable in coding and reimbursement issues and understand the claims process from the
payor’s perspective. Background checks on panel members should be performed to ensure that there are no sanctions or other legal issues. Once your clinical panel is established, outline its activities in a policies and procedure manual. Include quality-assurance guidelines, such as specific instructions preventing application of edits or other means of denying claims, which are not grounded in the rules contained in industry standards (i.e. CMS, CCI, or NCI). Your emphasis should always be objectivity in evaluating claims according to current standards of practice in medicine and dentistry. Protecting the patients care and treatment should always be the mandate, and in doing so, the business objectives of the payor will be met by fair and equitable distribution of benefits. By establishing a clinical panel, your organization can meet fiduciary and state regulatory responsibilities while improving provider network relations and protecting the public from the theft of benefits.
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egardless of political affiliations, income levels or religious beliefs, most American’s across the nation agree on one thing – Something must be done about the skyrocketing costs of health care. With health insurance premiums growing four times faster than wages, bankruptcy is getting the better of many citizens. Given the current financial reality of our economy, some in Washington argue that we should defer health care reform – again. On the other hand, many realize that the same costs that are straining family budgets are also putting companies of all sizes out of business and depleting government budgets, prompting a call to arms for the immediate reform of health care in our country. The challenge to make meaningful enhancements in health care will depend on radically reforming the structure of the general deliv-
ery system. Current conditions should not promote continued nonreaction to the issue. Instead, they should emphasize the need for strategies that both address existing weaknesses in quality and efficiency and further the positive improvements that have already been made in health and medical innovation. The idea of health care reform is often presented as two extremes: Governmentadministered health care with higher taxes or insurance company operated health care without rules. Believing that both extremes are wrong, President Obama wisely opened the White House East Room to numerous, diverse leaders with often conflicting views for a blunt discussion on how to achieve the goals of lowering health care costs and expanding coverage. The March 5th conversion of senators, state representatives, major associations, doctors, nurses and health
It seems the dark cloud that has been shadowing U.S. health care for decades is developing a silver lining
care administrators, encouraged the sharing of candid opinions, resulting in beneficial dialogue and a commitment to work together in order to pass an effective health reform plan. As Nancy-Ann DeParle, Director of the White House Office of Health Reform, recounted in a March 30th blog post, “Consensus is rarely easy to find on an issue that touches our lives so intimately and our economy so profoundly. But in nearly two decades of working on health care issues, I have never seen a discussion as open and productive as the one the President led.” It seems the dark cloud that has been shadowing U.S. health care for decades is developing a silver lining. In the Administration’s report on the White House Forum on Health Reform, released March 30, 2009, President Obama states, “In this effort, every voice must be heard. Every idea must be considered. Every option must be on the table. There will be no sacred cows in this discussion. Each of us must accept that none of us will get everything we want, and no proposal for reform will be perfect. But when it comes to addressing our health care challenge, we can no longer let the perfect be the enemy of the essential.” As active consumers, providers and payors, we all play a part in the overhaul of our current health system. Let your voices be heard. Visit www.healthreform.gov to learn more about health reform and how you can lend your support. Join the discussion by sharing your stories and ideas, read the White House Forum on Health Reform report and discover all the latest health reform happenings.
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eet Joel Portice, recently appointed Chief Operating Officer of HealthCare Insight (HCI). Joel brings more than 18 years of experience in health care management, claims software and analytics to HCI, as well as an extensive background in operational business development and systems integration. Combining his efforts with HCI’s fraud detecting analytic software and a skilled team of licensed clinicians, Portice is quickly making strides to discover new methods of combating fraud, abuse and overpayment in the health care industry. Known for his fact-based decision making skills and ability to effectively connect with clients and colleagues alike, Portice is geared to make an impact and leave a lasting impression.
Profiler Magazine: What career steps lead you into medical fraud? Joel Portice: While attending graduate school in Minnesota, I worked at Equifax Services and was introduced to health care fraud prevention. I found it highly interesting and undercapitalized in terms of companies investing in sophisticated and predictable solutions. I also saw a general lack of public awareness regarding the issue and an opportunity to add value to the inefficient health care industry. After completing graduate school, I co-founded a business that developed rules-based and data-driven detection services. Our emphasis was on the payor segment of the health care industry. After dabbling in claimant, disability and workers compensation fraud, we ultimately focused entirely on medical fraud as perpetrated by providers, resulting in rapid growth. The company was eventually acquired by a large health care payor. PM: Serving as a legislative aide to United States Senator Tom Daschle introduced you to health care policy. With our nation currently debating health care reform, what changes would you like to see occur? JP: The most pressing issue is to improve access and quality while reducing the economic burden health care has on American families. It is the number one cause of bankruptcy in our country today, and premium increases have regularly risen faster than the rate of inflation over the past several years. The World Health Organization consistently rates the quality of care below many other industrialized countries. We have great doctors and technology in this country, but the administrative burden and errors affecting our health care system are restricting the quality. With the continued shift of risk moving to providers and consumers, there will be greater demands on transparency and quality, requiring improvements in administrative efficiency. PM: What area of health care needs the most attention in terms of preventing fraud and abuse? JP: Payors still control 90 percent of the benefit payments in the industry and are critical to the handling of health care claims. They represent the largest constituency and can have the greatest influence on stopping fraud. Payor acceptance and implementation of sophisticated fraud-detection
tools are required to address the problem. Public awareness and consumer participation are also necessary in the effort to reduce health care fraud. PM: How can reducing fraud affect the entire health care system? JP: The reduction of fraud will help ensure health care expenditures are appropriately allocated. Everyone talks about how expensive health care is. It is substantial and will soon consume 20 percent of the U.S. Gross Domestic Product, but no one knows what it should cost for our society. Reducing fraud, waste and abuse promotes suitable spending practices that will have a positive impact on our ability to care for the sick and injured. PM: What advice can you give consumers to guard against fraud and medical ID theft? JP: Review billing statements and EOBs. Ask questions of providers before services are provided to ensure it is medically necessary. If a discrepancy is identified, be sure to notify the claims administrator. PM: What goals would you like to see HCI achieve in the coming years? JP: I would like to see HCI continue to maintain significant growth in terms of revenue and profitability, refine business practices, and further demonstrate the industry’s most reliable and sophisticated anti-fraud solution. We must also recognize the benefits of strong, positive relationships with our customers and partners, and maintain a culture in which employees are proud to be accountable for their performance and experience professional advancement.
Away From the Office Favorite Book: To Kill a Mockingbird Favorite Hobbies: Spending time with family Favorite Movie: The Godfather (1 and 2) Favorite Vacation : Anywhere in the South Pacific Favorite Quote: “The measure of a man’s real character is what he would do if he knew he would never be found out.” – Thomas B. Macaulay
Heat Up Your Marketing
by Darin Johnson, MBA
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arketing is a fad-driven business function and today’s buzz term is social media. What is social media? Web Pro News defines social media as “the online tools that people use to share content, profiles, opinions, insights, experiences, perspectives and media itself, thus facilitating conversations and interaction online between groups of people. These tools include blogs, message boards, podcasts, micro blogs, bookmarks, networks, communities, wikis and vlogs.” Social media is important because it provides an opportunity for your business to leverage cost-effective (free in most cases) mediums with built-in audiences to increase distribution of all marketing communications and better connect with influencers, stakeholders and consumers with greater speed and frequency. Social media is all the rage in marketing today and it’s not going away any time soon. Sensing this, marketers have rushed to sign-up for Facebook, Twitter and YouTube accounts to keep up with current trends, but without a clear game plan for success resulting in wasted time and resources. “Heat up” your social media efforts by following these simple guidelines.
With more than 8 million* victims each year at an estimated cost of $50 billion*, it’s not surprising that we’ve all heard horror stories about identity theft and fraud. Luckily for consumers, there are hundreds of businesses delivering identity theft protection services to preserve personal privacy and credit. But with annual health care fraud losses reaching an estimated $255 billion and the number of insured Americans soon to surpass 50 million, who’s protecting your medical identity? When your wallet or purse is stolen, you immediately call and cancel your credit cards and notify your banks of the theft. But did you think to call your health, dental and vision insurance companies and report your insurance cards stolen? An insurance card is just as valuable, if not more so, than a credit card. Thieves can use your health insurance card to get medical treatments and expensive surgery, as well as prescription drugs, leaving you responsible for the bill. Medical identity theft is difficult to detect because you may not know about it until you receive a bill or collections notice from a medical provider. And the impact of having your medical ID stolen goes beyond the financial impacts. Thieves can change the information in your medical record by updating your list of allergies, family history, or even your blood type. They can also change your address and other contact information to keep you from receiving provider notices. These types of changes can cause life saving treatments to be skipped based on a noted allergy you don’t actually have, or provide you with the wrong blood type if you were severely injured and unable to communicate with the attending doctors. You may even be denied access to your own medical file under HIPAA’s privacy regulations.
There are several things you can do to protect yourself from this type of theft:
Check your Explanation of Benefits (EOB) after each doctor’s visit to ensure that all office visits and procedures noted are accurate. If you lose your insurance card, call your insurance provider immediately to inform them of the loss and request a new insurance card AND number. Simply getting a new card doesn’t protect you if the thief has your ID number. Always cross shred personal documents when disposing of them. Request a copy of your medical records and review them thoroughly for any discrepancies. It’s much easier to get a copy of your medical file before you’re a victim than after. Ask your HR representative if your company’s health, dental and vision plans are analyzing all claims for fraud, abuse and overpayment. (Fraud prevention requires commitments from all parties.) Also consider contacting your insurance company to inquire about technologies and practices utilized to detect and prevent fraud. Write a letter or send an email to your state and federal congressional representatives asking that they mandate health care fraud prevention in your state. Visit www.stophealthcarefraud.com to stay abreast of news and tactics to help you guard against medical identity theft.
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