Posts Tagged 'Fraud'

Doctor Hunt: Practicing What I Preach

I’m proud of my husband and the reason holds a good lesson for us all….

Over the past six months or so, our experiences with our family doctor’s practice have been less than acceptable. First, Hubby contacted their “prescription refill hotline” about three weeks before his arthritis prescription ran out. He needed a new prescription and knew it would take some time to get it….but…. two weeks later he had to call them again. Then the next day, then the next. He was told they had called in his prescription to our pharmacy but — no — the pharmacy had no record. Eventually, because he had run out and was in pain, he stood at the pharmacy counter while they called the doctor’s office. Not right.

Turns out that part of the problem was that his doctor had left the practice! Of course, no one bothered mentioning that, nor had they bothered to tell him he had been “reassigned” to a new doctor — a 30-something woman who I’m sure is a fine doctor — but not for my 50-something husband who would prefer a male doctor!

Hubby is not a happy camper.

I ran into my own problems. I go for an annual checkup each fall. I made my appointment a couple months ago and was told to go in a week or so ahead for a blood draw. OK. I asked whether I needed to fast for the blood draw. Nope, I was told. That’s not necessary.

So, Monday, I called the doctor’s office to make sure all the paperwork had been done so I could go to the lab for the blood draw on Tuesday. “It sure is,” I was told, “They are a part of our system, so they have all your paperwork in the computer.” I asked again — are you sure I don’t need to fast? No — no need.

So I headed to the lab about 3 PM Tuesday. You guessed it. Yes, they found my records — but — the labwork request had been cancelled. Huh? Long story short — not only did I have to go back to the doctor’s office to straighten it out, but it turns out that yes, I did need to fast for the blood draw!

My doctor happened to walk into the reception area of the office while I was there. She asked why I was there (knowing, I guess, that I had no appointment) — and I told her I was there to straighten out the blood work fiasco. I asked her– fast or no fast? “Of course you have to fast, unless you want to be unhappy with the results!” she replied flippantly as she turned around and marched out of the room.

OK — so now I’ve gone from annoyance to ticked-off.

So these are two VERY BASIC services that require no rocket science whatsoever to handle. If they can’t do any better than this with the basics, how can we be sure they will handle anything of any consequence correctly?

So Hubby and I decided together we would begin to look for a new practice to move to — and yesterday Hubby began checking with our insurer to see who else is on their list of providers.

He narrowed his search down to a half dozen doctors — and then — he started researching them. He didn’t ask me for advice, instead, he just started poking around the internet. Sure enough, he found information that one of the doctors on his list has been fined $2,500 for some kind of squirrely billing practices. (I translate that as the possibility of Medicare Fraud — but I don’t know that for sure.)

Our next steps are to begin asking others whether they know any of these doctors to see if we can find happy patients. We’re not really in any hurry — thankfully — because we are both healthy and we’ve had all the 50-something tests we’re supposed to have, etc.

I’ll keep you posted on the great doctor hunt. Just wanted you to know that it can be done, and will be done.

Gotta let you know that yes — in our home — we practice what I preach.

Paging Marcus Welby!

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Prescription Dangers = ID Theft Possibilities

Still in Sarasota, FL visiting my parents and almost dropped my teeth at a story Dad told me last night. See what you think.

Several years ago, Dad began receiving materials about heart health from the local pharmacy, part of a national chain. He tossed them; in his mid-70s, Dad’s heart was going strong (still is!) and the information was about drugs he had never taken.

A few months later, for record keeping purposes, Dad requested and received a list of all the drugs he had purchased from that same pharmacy. As he looked over the list, he found references to many drugs he knew he had never been prescribed, had never had any need to take — all heart related — including coumadin and others.

OK — so that explained why he had been receiving those health intelligence materials — presumably a nice service from the pharmacy.

But — ding ding ding!! Alarm alarm alarm! Why on earth were those heart drugs listed on Dad’s account? Who did they belong to? And who had paid for them? Going back a few years, the total cost had been almost $20,000! Because Dad has an excellent prescription plan through his pre-retirement, self-insured employer, it was that employer who had paid all that money.

Dad contacted the administrators of his prescription insurance group which, as mentioned above, were people within the company he retired from (because they were self-insured. Large corporations often are.) They sent security personnel to Florida to investigate. Afterall, it appeared that someone had fraudulently obtained prescription drugs at the expense of Dad’s company.

Dad only knows part of the rest of the story…. turns out there was a man who lived in Tampa with his same name. The man’s prescriptions had all been phoned in to another branch of the same pharmacy chain and their accounts had become mixed up within the pharmacy’s computers. The man’s wife had been picking up the prescriptions, paying the copay — Dad doesn’t know whether she knew the accounts were mixed up or not. She may have been completely unaware, or she may have realized they had a good thing going and continued to capitalize on it. Afterall, the drugs were costing her only $3 copay. $20,000 later, one can only hope that at least her husband’s heart was still going strong.

The story is interesting from a number of angles — but it set off some alarms to me that had less to do with the possible fraud, and more to do with Dad’s safety and medical identity theft.

Safety: so suppose Dad had been in Tampa for some reason, and had taken sick. Suppose the had been rushed to a Tampa hospital. Is it possible the records from the pharmacy about his drugs could have gotten mixed up with his real records? What if he wasn’t conscious… would they have given him some of those heart drugs? I don’t know the answers. I’m just throwing out the questions.

ID Theft: so suppose Dad hadn’t been so interested in his history of purchases from the pharmacy. Would that same person have continued to purchase drugs through Dad’s insurance? Would there be a history somewhere that Dad had heart disease because those drugs were on his records? Suppose he had then been turned down for a co-insurance program somewhere else, or that his company would have been defrauded further? Could that person have also been able to obtain Dad’s insurance account numbers, and from there, social security numbers or other identification that could have then turned into identity theft?

The questions remain, but they are a good reminder to all of us….

Every step along the way of our health transactions, we need to double check that the care and drugs and other treatments we need or receive are ours, and ours alone. When you visit the doctor’s office, ask to review your records to be sure they all belong to you. When you pick up a prescription at the pharmacy, ask to review the list of drugs they have on file for you to be sure they are all drugs you’ve been prescribed. And make sure they match up at least your birthdate in addition to your name. If you have a common name, be even more diligent.

Fraud, or mistakes? Intentional or accidental? When it comes to our health, and the overall ramifications of identity errors, we can’t ever be too careful.

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Just a “little” medical fraud

An elderly friend recounted this story to me. He’s upset. I’m upset. And I expect by the time we’re finished, the doctor will be more than a little upset, too.

Mr. Z is 90 years old, and except for macular degeneration which renders him mostly blind, he is very healthy and quite sharp. He lives by himself, but gets along and around quite well.

Last week, Mr. Z went to his podiatrist to get his toenails clipped, and when the doctor was finished, he exclaimed, “There you go, Mr. Z. Your corns are all taken care of.”

“Corns?” asked Mr. Z. “I didn’t have corns– all you did was clip my toenails.”

“Sure — you have corns!” Mr. Z was told. “Otherwise you’ll have to pay me out of your pocket!”

By the time Mr. Z returned to his apartment, he had figured out what it was all about. And he was upset. That’s why he told me the story. He realized the podiatrist was going to bill his insurance, or perhaps Medicare, for a procedure he didn’t really have. It made him mad.

Do you know who DID pay for that toenail clipping AKA corn repair? You did, and I did. Mr. Z surely didn’t pay for it, and the podiatrist probably made twice as much money on the transaction than he would have made had Mr. Z written a check. No doubt insurance and Medicare (maybe he billed them both!!??) pay more for corn repair than an individual pays for a toenail clipping.

As smart health and medical care consumers, we must be watchful when doctors and facilities get reimbursed for the work they do on us. If we were writing checks, or paying cash from our pockets, no doubt we would review billings carefully. But with insurance or Medicare as a middleman, it’s easy to let it go. That is one reason, of course, why insurance prices just continue to go up and up.

And when you find a discrepancy? Start by checking with the doctor or facility that was reimbursed. Give them a chance to explain it to you, or to change it.

If you feel they are trying to do something illegal, report it to the payor — your insurance company or Medicare. Here’s a link to the Medicare fraud reporting agency.

Do you want to pay for work that wasn’t done? Do you want to pay for everyone else’s healthcare? Does this make you as mad as it makes me?

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