Fast Facts and True Stories about Health Care Fraud

In 2008, Americans spent $2.34 trillion dollars on health care.  The Federal Bureau of Investigation (FBI) estimates that between 3 and 10 percent (between $70 billion and $234 billion) was lost to health care fraud.  $234 billion dollars is roughly the equivalent to the Gross Domestic Product of a nation the size of Columbia or Finland.

But the “costs” of these scams is not just measured in dollars and cents.  In June 2010, a doctor and his wife were convicted of running a “pill mill” that appeared to be a pain management practice in a Kansas.  The couple dispensed controlled prescription drugs; and collected more than $4 million from 93 different private health insurance and government health care programs.  The doctor was found to be responsible for more than 100 overdoses and at least 68 deaths over a six-year period.

Another organized health care fraud ring involved 5 states in pretend clinics and resulted in claims for approximately $110 million dollars in false claims.  In order for this “practice” to work the group also utilized identity theft techniques which allowed them to steal the identities of legitimate Medicare beneficiaries.  They were convicted in January 2010.

In Feb. 2011 FBI special agents broke up a health care fraud scheme in Puerto Rico and arrested approximately 200 of the 533 people named in the federal indictment. The scheme had been going on for years and involved false accidental injury claims made by policy holders and supported by certain doctors and medical professionals.

Feds Launch Most Wanted List for Health Care Fraud

Yes, it’s true the U.S. Department of Health and Human Services Office of Inspector General has launched a website with the 10 most wanted health care fraud criminals. These “fugitives” are accused of having cost tax payers over 124 million dollars in health care fraud.  However, they are actually seeking more than 170 fugitives on charges related to health care fraud and abuse.  The fugitive’s names, date of birth, descriptions and pictures are available on the website which is updated when they are apprehended.  You can even report a fugitive.

“We’re looking for new ways to press the issue of catching fugitives.  If someone walks into a bank and steals $3,000 or $4,000, it would be all over the newspaper. These people manage to do it from a less high profile position, but they still have a tremendous impact,” says,” said Gerald Roy, deputy inspector general for investigations at the Health and Human Services Department.

On the most wanted list:

Meet Leonard Nwafor; convicted of billing Medicare for more than $1million dollars for motorized wheelchairs that were not needed, one such “recipient” was blind.  Convicted of a federal crime and facing time in a penitentiary, he has disappeared.

Sisters Clara and Caridad Guilarte allegedly submitted $9 million to Medicare in false and fraudulent claims infusion drugs that were never administered, and offered rewards including cashing for those who agreed to visit their clinic in Michigan, and sign forms saying they received services which they didn’t.

Miami brothers Carlos, Luis and Jose Benitez were owners of a string of medical clinics.  They are accused of allegedly   “scamming” Medicaid out of out of $119 million by billing for costly HIV drugs that patients never received or did not need.

“Scammers often utilize their ties to a particular community. They take advantage of ethnic communities based on language barriers or lack of knowledge about how the Medicare system works. These folks are exploiting low-income communities,” says Gerald Roy, deputy inspector general for investigations at the Health and Human Services Department.

“With our Most Wanted Fugitives List, OIG is asking the public’s help in tracking down fugitives,” said Daniel Levinson, the HHS’ inspector general. “(It) has a stake in the fight against fraud, waste and abuse.”

Resources and Sources

Report a health care fraud fugitive

Ten most wanted list US Dept. of Health and Human Services OIG

National Health Care Fraud Association White Paper

FBI

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The Security Rule, a Federal law that protects electronic health information, requires HIPAA-covered entities to ensure that electronic protected health information is secure.

Additionally, HIPAA includes protections limiting exclusions for preexisting conditions; prohibits discrimination against employees and dependents based on health status; and allows an opportunity to enroll in a new plan to individuals in certain circumstances. HIPAA may also grant a right to purchase individual coverage if no group health plan coverage is available, and for those who may have exhausted COBRA or other continuation coverage.

You have the right to receive a copy of your health records

You can ask to see and get a copy of your medical records and other health information. In most cases, copies must be provided within 30 days of being requested, though there may be a fee associated with the cost of copying and mailing.

You can ask to have corrections added to your health information

You can ask that any misinformation in your file be corrected, or you may request to add information to an incomplete file. For example, if you and your hospital agree that your file has the wrong result for a test, the hospital must change it. Even if the hospital believes the test result is correct, you still have the right to note your disagreement in your file. In most cases the file should be changed within 60 days of the request to amend or change.

You can receive a notice that tells you how your health information is used and shared

You have the right to know how your health information is being used and shared. Your provider or insurer must give you a notice that tells you exactly how they may use and share your health information. In most cases, you should receive this notice on your first visit to a provider, or in the mail from your health insurer. Additionally, you may request a copy at any time.

You can decide whether to give your permission before your information can be used or shared

Generally speaking, your health information cannot be given to your employer, used or shared for things like sales calls or advertising, or used or shared for many other purposes unless you grant express permission by signing anauthorization form. This authorization form must tell you who will get your information and what the information will be used for.

Who must follow this law?

Most doctors, nurses, pharmacies, hospitals, clinics, nursing homes, and other health care providers. Also required to follow this law are health insurance companies, HMOs, most employer group health plans, and certain government programs such as Medicare and Medicaid.

Who receive and view your health information

To ensure your health information is protected in a way that does not interfere with treatment, your information can be used and shared:

• For treatment and care coordination;
• To compensate doctors and hospitals for your health care and help run their businesses;
• With your family, relatives, friends, or others you identify who are involved with your health care or payment, unless you object;
• To ensure doctors give good care and nursing homes are clean and safe;
• To protect the public’s health, such as by reporting when there is a flu outbreak; and
• For mandatory reports to the police, such as reporting gunshot wounds.

Your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot:

• Give your information to your employer;
• Use or share your information for marketing or advertising purposes; or
• Share private notes about your health care.

You may request that your information not be shared

You can ask your provider or health insurer not to share your health information with certain people, groups, or companies, such as with other doctors or nurses in a particular hospital or clinic. However, they do not have to agree to do what you ask.

You have the right to file a complaint

You may file a complaint with your provider or health insurer if you suspect your information was used or shared in a way that is disallowed under the privacy law, or if you feel you were unable to exercise your rights.

Who Is Not Required to Follow These Laws

• Life insurers;
• Workers compensation carriers;
• Most schools and school districts;
• Many state agencies, for example child protective services;
• Most law enforcement agencies; and
• Many municipal offices.

When you make an original visit to a doctor’s office, hospital, or other health care provider, you should be given a copy of your HIPAA rights, which you will be asked to sign. Make sure you read the entire document, and request a copy for your own files.

Links:

How to file a complaint

HIPAA FAQs

Notice of privacy practices

Summary of HIPAA privacy rule (PDF)

U.S. Department of Labor HIPAA pages

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AFLAC stands for American Family Life Assurance Company of Columbus (Georgia). AFLAC offers supplemental insurance products and this means that these are insurance policies that are above and beyond traditional policies. The supplemental policies can help fill in the gaps during a medical crisis. They can also cover areas that aren’t offered by your employer healthcare such as dental insurance or long-term care insurance.
What insurance products does AFLAC offer?
Accident Indemnity
Disability Income Protection
Cancer Indemnity
Hospital Protection
Life Insurance
Dental
Long Term Care
Paid Directly to You:
AFLAC supplemental insurance policies pay above and beyond traditional insurance policies and they pay directly to you. Policyholders can request a payment be made directly to a medical provider, but otherwise all payments will come directly to the customer.
Here’s an example of how a cancer indemnity policy may work.
If you purchase a policy for cancer indemnity that offers a $10,000 benefit and you are diagnosed with cancer, AFLAC will pay you $10,000 directly. This is your money that you can use however you choose. It may be used of course to pay for medical bills not covered by traditional insurance but it is yours and that is your decision.
One costumer we talked with had an AFLAC cancer indemnity policy when he was diagnosed with prostate cancer. He used the insurance money helped to cover:
-Medical bill balances not paid by insurance
- Soaring phone bills due to making appointments and keeping in touch with family
-Gas money for the extra travel to and from treatments
-Meals when traveling
-To pay off debt which relieved some stress during his time of illness
Of course AFLAC offers many products in addition to cancer indemnity products.
Portable:
Another way that AFLAC is different is that it is portable. Even though you may enroll in AFLAC through an employer (or not) you pay your own premiums, or you can have them deducted from your paycheck and your insurance can go with you if you lose your job, change jobs or move. In today’s mobile world and in such a volatile employment climate, the portability of AFLAC insurance is a big plus.
Price:
AFLAC is well-liked for these good points, as well as others such as easy claim forms that are available online and the fact that AFLAC plans also pay for some preventative services that many traditional plans don’t pay for, but what about price? AFLAC is generally considered to have higher premiums than competitors but many feel that the ease, such as insurance without an exam, makes the cost worth it for an AFLAC supplemental policy.
Point of Purchase:
Some people point out the frustration that you cannot buy an AFLAC supplemental insurance plan online which is common with many insurance companies but this may really be a plus since meeting with a representative can insure that you understand all of the details on the insurance products that you are purchasing.
Customer Service:
Most customers report positive experiences with sales representatives and customer service reps although company administrators that oversee insurance benefits have privately said that customer service can be inconsistent which seems to be on par in the insurance industry.
Positive points about AFLAC:
-Pays you directly
-Portable
-Many products
-Simple claim forms available online
-Pays for some preventative care
Complaints about AFLAC:
-Higher premiums
-Inconsistent costumer service
-Can’t be purchased online
AFLAC products are unique and they have proven that they deliver on their positive points such as keeping claims easy and paying directly to you the customer. In the end, if you are in the market for supplemental insurance, you’ll have to weigh the higher premiums against the conveniences and well-known name of AFLAC.

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