So today started out as any normal day, the marketing department was hard at work on their projects when all of a sudden - our CIO flew into the room - “You will never believe what happened!”

It was hard to believe.

Anyone who constantly monitors the Medical Fraud, Waste and Abuse business probably saw the news today, New York recovered more than $551 million in Medicaid fraud this year alone, more than double what officials had estimated. The shocking part of this news, was the press release that followed it. The New York State Comptroller, Thomas DiNapoli came out with a statement that the system New York has been using - isn’t working. The Comptroller’s office had recently overseen an audit of the system and turned up $1.8 billion in overpayments.

We come across fraud, waste and abuse daily - but we don’t normally come across a figure as large as $1.8 billion. After reading through all the issues we found that many of the problems facing New York were the same issues that our potential clients face, but without the $1.8 billion pricetag.

The Comptroller identified a few cases of fraud that had gone undetected by the system and most likely - would go undetected in most systems available today (except our own). Why is that? Most systems create edits based on federal guidelines and codes and leave it at that. We know better than that. Because we’ve been in this business for more than 35 years, we know that the rules do not include common sense rules. Long ago when edits were done manually, that was understandable but now you have to include these rules in your editing software. We have common sense edits in our system that would notice that it’s illogical to give one patient 35 fillings in one day.

Let’s hope that the next iteration of New York’s system will include logic as well as the required guidelines, and that they’ll be able to figure out when guidelines and rules are in conflict with another and how to rank them so that the edits follow all guidelines!

That took us several years to do on our own, but it’s been worth it. The last time one of our clients was audited, nothing came up. Zero! Nada! The auditors weren’t able to come up with anything wrong with their system.

It’s always nice when you find out all your hard work was worth it.

Here at AMG-SIU we come across interesting cases of fraud, waste and abuse all the time – but today, we came across fraud from a completely different source – the news.

Today it was reported that a man committed identity theft from a Medicaid patient to receive heart bypass surgery. Typically when you see someone steal an identity for medical benefits – it’s a one-time event: not for John Parsons. Parsons repeatedly committed fraud to secure a heart bypass surgery.

I’m probably wondering the same thing you are – how did he do this?

According to initial reports, it was not the internal or external vendors who caught the fraud: it was the caregiver of the man whose identity was stolen, Philip Johnson. Our own solution reports when any permanent characteristic is inconsistent with what we have on file such as birth date, sex, height and so forth – so we’ll be watching this story closely to make sure our own solution is capable of finding this type of fraud.

According to the “Financial Crimes Report“, the FBI estimates that between 3 and 10 percent of the $2.26 trillion spent on healthcare services are fraudulent. Healthcare fraud could cost Americans as much as $226 billion annually.

CMS identified $371.5 in Medicare overpayments in California, Florida and New York for the 2007 fiscal year. For more information please read their press release.

AMG-SIU’s IT staff was attending the Microsoft launch event for Windows Server 2008, SQL Server 2008 and Visual Studio 2008 in Los Angeles, CA. Microsoft demonstrated lots of new features during the many sessions and the keynote speech.

On Tuesday, December 11th, 2007, AMG-SIU attended the 4th Nationwide Health Information Network Forum, which focused on sharing experiences from trial implementations of several HIEs (health information exchanges). The event gave the public a chance to interact with stakeholders from the public and private sector, including government and industry representatives. Work is continuing on standards harmonization through HITSP, the Health Information Technology Standards Panel, coordination of efforts/governance under the proposed AHIC 2.0 (American Health Information Community) with the Office of the National Coordinator of Health IT, and in many other organizations.

One of the most exciting and useful implementations of an HIE presented was that of the Camino de Salud/Long Beach Network for Health, which implemented a web-based electronic health record which, according to their studies, has actually been quite well received by their organizational stakeholders. Interestingly, this project consulted with the Kay Center for e-Health Research at the School of Information Science at Claremont Graduate University. AMG-SIU is proud to have three employees who are alumni of the CGU school of IS!

The challenges posed by creating such a large-scale, interconnected system such as a national health information network are no doubt immense and akin to the challenges in building the original Internet. With the enormous public and private support behind the effort, even if such a system is not adopted by everyone, the benefits of such a system may offer tremendous value for those who do use it. AMG-SIU wishes all stakeholders many successes and a safe, secure, private, vibrant and healthy future!

The US Justice Department received over $1.5 Billion in settlements from Medicare and Medicaid fraud cases during the 2007 fiscal year.

According to the latest statistics, health insurance companies can save over $100 per member per year. A common return on investment (ROI) is around 1,000%. This means that for every Dollar spent on fraud, waste and abuse initiatives they save about ten to eleven Dollars.

As expected, CMS was not able to disseminate the National Provider Identifier (NPI) data in a usable format, even after delaying the release multiple times. The first version of the downloadable file contained the text qualifier in the data. Also, there is no free version of the taxonomy codes. The data is only published as a PDF. Companies are forced to purchase a copy of a usable file.
It is ridiculous that the government forces companies to comply with their rules and regulations but is unable to provide the means to do so.

In an article called “Slicko“, Forbes reports that most health insurances spend about 20% too much on medical claims due to fraud, waste and abuse.
In their opinion, this is a bigger problem than the wrongful denials mentioned by Michael Moore in his movie “Sicko”.
AMG-SIU discovers lots of problems in different areas, including ineligible members, not covered services and duplicate claims mentioned in the article.
AMG-SIU not only ensures the accuracy of edits, but also provides backup for their denials.