Healthcare is on the front page of newspapers all over the country and your can't turn on the news without hearing stories about it. True the healthcare system in the USA could be better, and one way to improve it is to reduce healthcare fraud. To illustrate the dollar amount involved, a fellow private investigator in California told me about an investigation she conducted on a pharmacy that was allegedly engaged in fraud. A pharmacy in the LA area who employees 5 people, including a delivery diver, and bills over $400,000 a month. When you enter the pharmacy, there are very few customers and the phones were silent. She compared that to a legal pharmacy that is open 24 hours a day and may bill Medi-cal between $44,000 and $46,000. Big difference.
But just what are they doing and how are they doing it? Fix yourself a glass of tea or something and read on. It could save you money and Americans millions.
TYPES OF FRAUD:
Providers bill for services not rendered. Patients are out of state, in prison, or unaware that their medical card number is being used to pay for medicine, lab test, or adult day care, Or, in many cases, the beneficiary is an accessory to the fraud and has been paid to see the doctor or visit a pharmacy. I guess you could say this is type of "health identity theft."
Cappers and Runners are individuals who gather prescriptions from low paid medical workers, beneficiaries or even doctors, and sell them to pharmacies, labs or other providers. They forge additional prescriptions, or have the doctors write out a prescription for what brings in the largest amount of money. Many are mid to low level street drug dealers who have a good knowledge of their area.
Providers and Doctors give the patient a "paper illness" such as diabetes, heart disease or a STD. Most of us were brought up believing that a doctor was nothing short of a god, but God knows there are bad apples in the barrel, and the medical profession is no exception. By claiming a beneficiary has serious illness, they can bill for medications in some cases costing over $10,000 a month and pocket the money.
Providers and Doctors have a kickback arrangement. Patients are allowed to fill their prescriptions at ONLY at one pharmacy. Doctors pay beneficiaries off in prescriptions and drugs. The current favorites are Codeine cough syrup, Viagra, Vicodin, and Valium.
Home Health Care. Some states, like California, pay relatives or friends of the patient to be home health aids. They are paid for running errands, shopping, or helping the elderly in any other way. There is almost no over sight and in California alone, the fraud is estimated in several millions of dollars.
Adult Day Health Care. This is when the government pays for special care for dependent adults and elderly. Here again, there is little regulation or accountability on the part of the center, according to the investigation. Many are understaffed, and they have "kickback" deals with the suppliers of food, medical equipment, and so forth.
Drug substitution. One drug is prescribed, but a higher priced one is billed to the governmental program while the patient receives a cheaper drug. This is most often found with Zyprexa 10 mg., a psychotropic drug that cost about 6 times more than other drugs in the same category.
Street Drug Sales and Smuggling. Prescriptions for a desirable street drug is forged by the pharmacists, the program that is in place is billed and the drug is then sold on the street often out of state. Texas and Louisiana are reportedly the states of choice for one pharmacy that was illegally exporting truckloads of Codeine Cough Syrup.
Lab Fraud. Lab work is ordered by less than scrupulous doctors for extensive, expensive, and not needed test, and the profits are split by the doctor and the lab.
These are but a few of the methods used to comment fraud in the American Healthcare system, but here are more. What can you do? First, know your doctor or healthcare provider. Do some research before your visit. Check out their credentials with the AMA and your state's regulatory board. Don't be afraid to ask questions. If you aren't satisfied with the answer, tell the doctor. Get a second opinion. When you get your prescription filled, read the label right then. Make sure that what is in the bottle is what the doctor ordered. If you are faced with the decision to place a loved one in an assisted living facility or nursing home, do extensive research on all aspects of the facility. Make unscheduled visits, and, again, ask if something just doesn't seem right to you and don't stop until you are satisfied with the answer. Last but not least, email or write your elected officials about your concerns. It is the lawmakers who are responsible for passing laws that will reduce or eliminate fraud.