Health Care Fraud – The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with ‘sleight-of-hand’ precision?Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.1. Astronomical Cost EstimatesWhat better way to report on fraud then to tout fraud cost estimates, e.g.- “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]- The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.- The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don’t know and what we know that is not so. [The Cato Journal, 3/22/02]2. Health Care StandardsThe laws & rules governing health care – vary from state to state and from payor to payor – are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid – in some cases codes that do not accurately reflect the provider’s service.Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – especially if it is Medicare that denotes non-covered services as not medically necessary.3. Proactively addressing the health care fraud problemThe government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.4. Exorcise health care fraud with the creation of new lawsThe government’s reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws – presuming new laws will result in more fraud detected, investigated and prosecuted – without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments’ capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.What’s one person’s fraud (insurer alleging medically unnecessary services) is another person’s savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:- DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.- REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn’t paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient…- REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.- PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.- PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.5. Insurers are victims of health care fraudInsurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.6. Increased investigations and prosecutions of health care fraudPurportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters – steal up to a certain amount, stop and change jurisdictions?In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud – on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

Best Way to Find New Targeted Subscribers for Your Email Marketing Campaign

In the world of internet marketing, the most important asset is a target market. With the help of targeted email marketing, you can increase your online sales and profits as you can build a list of email subscribers who are interested in what you have to offer. In today’s lesson, I will provide you information about the elements of targeted email marketing, and how you can use it to build a list of email subscribers.First of all, you should know that, even before the formation of your email campaign marketing, you should gather the target market. You can do this by way of surveys. This will provide you with information about the target market’s interests. You can create different emails, and send them out to the target market in the form of surveys.When the email was sent in the form of a survey, you can ask them about their opinion about certain topics, and offer them the solution in order to solve their problems.The survey has been used in email marketing for years. However, in these surveys, you have to ask a lot of questions to get a wide range of information. This can be expensive and time-consuming.There are several companies or individuals that have decided to develop software for the purpose of email marketing targeted marketing. This software can do the task in a fraction of the time. These products have a wide range of uses in targeted marketing. One use is the use in the process of targeted marketing. In this, you can collect data and formulate a marketing strategy based on the collected data. This targeted marketing software is the most effective tool in email marketing targeted marketing.In email marketing targeted marketing, you should make sure that your list of email subscribers is targeted. That is to say, it is a list of email subscribers who are interested in your product or service. In order to attract a target market, you should create a marketing strategy that appeals to that individual. If you do this, you will attract a large target market.In today’s lesson, I will show you how you can use targeted email marketing to improve sales and profits. In this lesson, I will provide you with techniques that you can employ in your business. If you implement the techniques shown in today’s lesson, you will be able to improve your profits and sales.The first thing that you have to do is to make sure that you make the email marketing targeted marketing, and that is to make sure that you get permission from your subscribers. You should always ask permission from your subscribers. If you don’t, you will be violating CAN-SPAM law, and you may also be breaking other laws. This is also a part of your emails, and you should put it on all your emails.That is because, in the United States, CAN-SPAM will penalize you with an $11,000 penalty. This penalty will appear in your income for the previous 2 years. And in Canada, it will penalize you with a $5,000 penalty. And in the previous countries, it has penalized you with a 2,500 penalty. This is a law of the United States of America, and it is enforced. It will also appear in your sales and profits.Therefore, you will be in trouble. So it is always better to ask permission from your subscribers. The second thing that you should always include in your emails is for them to give up their email addresses. In that way, you will be able to send your emails to only people who have told you they want to receive emails from you. In that way, you will be able to improve your emails to only those people who want to receive emails from you.You do this by getting the subscribers to give up their email addresses. If you ask for permission to send emails to their inbox, they can always unsubscribe. And that way you will be able to better concentrate on your customers who want to receive email marketing promotions.

Importance of Health and Media Literacy

Although research suggests that children’s eating habits are formed even before they enter the classroom – children as young as two may already have dietary preferences based on their parents’ food choices – health education can play a vital role in helping establish lifelong healthy patterns early.Research shows that health education has a positive impact on health behaviors as well as academic achievement, and that the most effective means of improving health literacy is ensuring that health education is included in curriculum at all levels of education.U.S. schools educate 54 million students daily, and can provide not only an outlet to promote healthy behaviors for children and adolescents, but a place for them to engage in these behaviors, including eating healthy and participating in physical activity.The U.S. is in great need of an improvement in health literacy. In a 2007 UNICEF study, our country ranked last out of 21 industrialized countries in overall child health and safety. Approximately one in five of our high school students are smokers, 80 percent of students do not eat the recommended five servings of vegetables and fruits per day, and more than 830,000 adolescents become pregnant each year. Approximately two thirds of the American population is estimated to be overweight or obese.Furthermore, our understandings of health and health-related behaviors are often highly influenced by the media and media images – which can lead to inaccurate assumptions and negative health behaviors and attitudes.The importance of media literacy as applies to health educationSelf-esteem patterns also develop in early childhood, although they fluctuate as kids gain new experiences and perceptions. Because media messages can influence unhealthy behaviors, especially in adolescents, a comprehensive health education program must include not only health knowledge, but media literacy as it relates to psychological and physical health behaviors as well.”To a large degree, our images of how to be comes from the media. They are [a] crucial shaper of the young lives we are striving to direct,” writes resource teacher Neil Andersen, editor of Mediacy, the Association for Media Literacy newsletter.Media awareness, Andersen explains, can help teach students techniques to counter marketing programs that prey on their insecurities to promote negative behavior, can explode stereotypes and misconceptions, can facilitate positive attitudes and can help students learn how to absorb and question media-conveyed information.Because our perceptions of ourselves and others develop early, and because we live in such a media-inundated world, it is important that we address the conflicts inherent in media values versus our own values with our children and adolescents first, in a factual, positive, and coherent way.A comprehensive (age-appropriate) health program would therefore teach about these various issues at different stages of development. Pre-adolescence and adolescence are especially pertinent stages in an individual’s growth for discovering themselves and their place in the world, and it is during this vital time that media literacy is absolutely key to an influential and positive health program. Issues must be addressed that affect positive health behavior and attitudes, especially in teen girls, including:• Digital manipulation of the body in advertisement – Almost all of what we see in media has been altered or digitally manipulated to some extent.• Objectification of the body in media – Since the 1960s, sexualized images of men in the media have increased 55 percent, while sexualized images of women increased 89 percent, according to a University of Buffalo study. There are also 10 times more hypersexualized images of women than men and 11 times more non-sexualized images of men than of women.• Average women versus models – Models today are 23 percent skinnier than the average woman, versus 9 percent skinnier in the 80s.We live in a pop-culture that not only promotes a hyper-skinny-is-best attitude, but also discourages average or healthy body ideals and individuals from feeling good about simply pursuing healthy dietary choices – they feel they must resort instead to drastic (and quick) weight loss measures that put unhealthy stress on the body.For example, a study released in 2006 by the University of Minnesota showed that 20 percent of females had used diet pills by the time they were 20 years old. The researchers also found that 62.7 percent of teenage females used “unhealthy weight control behaviors,” including the use of diet pills, laxatives, vomiting or skipping meals. The rates for teenage boys were half that of girls.”These numbers are startling, and they tell us we need to do a better job of helping our daughters feel better about themselves and avoid unhealthy weight control behaviors,” concluded Professor Dianne Neumark-Sztainer. Over the five-year period that the study was conducted, moreover, researchers found that high school-aged females’ use of diet pills nearly doubled from 7.5 percent to 14.2 percent.What teaching health and media literacy can doWhen a colleague asked Doctor Caren Cooper, a Research Associate at the Cornell Lab of Ornithology, what the opposite of media was, she paused only briefly before answering, “Reality, of course.”"We each need logic tools to realize that all media is a representation of reality – if we don’t bring this realization into our consciousness, we are apt to forget and let our own reality become distorted: fostering a culture of over-consumption, eating disorders, sexual violence, and climate change deniers,” she explained.Teaching health education comprehensively in today’s rapidly changing world is important for fostering skills that students will carry with them for the rest of their lives, including:• Developing positive body affirmations – Accepting their bodies, accepting other’s bodies, and showing respect for one another. A good exercise would be to have them write down good things about each other – without the words beautiful, or descriptions of size, as well as what they love about themselves – both physical and character traits.• Understanding the importance of eating right – And that it’s not about “dieting.” Perhaps the biggest misconception is that as long as a person loses weight, it doesn’t matter what they eat. But it does, and being thin and being healthy are not the same thing. What you eat affects which diseases you may develop, regardless of your size, and diets that may help you lose weight (especially quickly) can be very harmful to your health over time.• Understanding the importance of exercise – People who eat right but don’t exercise, for example, may technically be at a healthy weight, but their fitness level doesn’t match. This means that they may carry too much visceral (internal) fat and not enough muscle.”Given the growing concern about obesity, it is important to let young people know that dieting and disordered eating behaviors can be counterproductive to weight management,” said researcher Dianne Neumark-Sztainer, a professor in the School of Public Health at the University of Minnesota. “Young people concerned about their weight should be provided support for healthful eating and physical activity behaviors that can be implemented on a long-term basis, and should be steered away from the use of unhealthy weight control practices.”We must also teach them:• How to reduce stress by engaging in activities and other outlets.• The importance of sleep.• The importance of vitamins.• The importance of not always being “plugged in” – The natural environment has great health benefits, and too much technology may even be hazardous to our health.”We’re surrounded by media images for such a large portion of our daily lives, it’s almost impossible to escape from it,” explained IFN representative Collete during an interview with EduCoup. “We get the majority of our information today through media, be it music, TV, the internet, advertising or magazines, so it really is incredibly important for us as a society to think about the messages we receive from the media critically.”Decoding the overload of overbearing messages, then, is pertinent to the health of our minds and bodies, and teaching these skills early will help kids to practice and maintain life-lengthening and positive behaviors for the rest of their lives.