Government Technology - February 2008 - (Page 28)

National Health Care Anti-Fraud Association conservatively estimates health-care fraud to be 3 percent to 5 percent of that expenditure amount,” she said. “That’s a significant amount of fraud, so we do have a strong interest in it.” Ogrosky said he began to see a trend in medical fraud schemes in 2003; the schemes run for 90 to 120 days then vanish. That’s because by the time victims notice irregularities in the explanation of benefits (EOBs) they receive from their health insurers, the thieves have moved on. “These schemes really started to pop onto our radar A survey of around 2003 and 2004,” 220 health-care Ogrosky said. “Since that providers and insurance compa- time, they’ve grown, stealing nies conducted in from our federal programs 2006 by the Health- to the tune of hundreds of millions of dollars, potencare Information and Management tially billions of dollars. I’ve heard different estimates. Systems Society and Phoenix Health There’s no real way to quantify the amount of fraud that Systems showed that only 56 percent we don’t yet know about.” Medical identity theft had complied with the HIPAA security can be a profitable venture, and it’s not that hard to requirements. pull off for someone who’s in a position to download large amounts of digitized medical data. In September 2006, police arrested a clerk at a medical clinic in a Weston, Fla., hospital who stole the medical IDs of 1,100 patients and sold them. The numbers were subsequently used to bill Medicare for $2.8 million in false claims. In another case, police arrested 38 people in Miami-Dade, Fla., in May 2007 and charged them with $142 million in Medicare fraud. The suspects had purchased or stolen medical ID numbers and billed the government for wheelchairs, walkers and other equipment. A thief downloading and stealing data can get $50 on the street for a medical identification number compared to just $1 for a Social Security number. For those receiving the medical ID number and using it to defraud a health-care organization, the average payout is more than $20,000, according to Pam Dixon,executive director FEB_08 “ IF YOU’RE BILLED FOR $1 MILLION OF MEDICAL EQUIPMENT BUT DIDN’T BILL THE OFFICE FOR A VISIT TO THE DOCTOR,THE DOCTOR’S NOT GOING TO BE NOTIFIED. Kirk Ogrosky, deputy chief for health-care fraud, U.S. Department of Justice ” of the WPF. Compare that to just $2,000 for the average payout for regular ID theft. Growing Sophistication Dixon said there have been cases involving Russian organized crime and identity theft rings that are buying health clinics and billing the government for services. There was a recent case in Milpitas, Calif., where two Ukrainian brothers purchased a medical clinic, and staffed it with fake doctors while getting collusion from at least one real doctor who provided his Drug Enforcement Agency number and UPIN so the group could bill for services and drugs. The clinic advertised free checkups, free food and transportation to patients in a povertystricken neighborhood. When the patients arrived, their Medicaid or Medicare cards were photocopied and subsequently billed for more than a year. In total, the group used the stolen numbers to bill for more than $1 million in medical services. “Those are the worst actors,” Dixon said. “What is just so terrible is it preys on the elderly and the vulnerable, and the only way this was found out was somebody was paying very close attention to her bills and noticed strange billing for treatment she hadn’t received. She raised a red flag and that’s how the entire ring got busted.” A check of the victim’s health insurance bill is usually the first sign that there is a problem, and most people don’t look closely enough at their paperwork. That gives the perpetrators ample time to pull off a scam and move on before being noticed. “Remember, claims to certain government programs are not going to go back to the doctor,” Ogrosky said. “If you’re billed for $1 million of medical equipment but didn’t bill the office for a visit to the doctor, the doctor’s not going to be notified.” That allows crooks to use a UPIN to bill for services without the doctor knowing about it. In another recent Miami case, a medical equipment company had more than 500 claims in 45 days — from deceased people. “When you see that sort of thing, it’s an immediate red flag that the data has been stolen,” Ogrosky said. Most of the cases originate from an insider with access to medical data, but there is also “one-time or limited misuse,” according to Calvin Sneed, senior antifraud consultant with the Blue Shield and Blue Cross Association. “If you looked at the smaller schemes, what you see is the ‘lending’ and ‘borrowing’ of ID by someone who can’t afford health 28 http://www.govtech.com

Table of Contents Feed for the Digital Edition of Government Technology - February 2008

Government Technology - February 2008 Contents Point of View Big Picture The Last Mile On the Screen Products Four Questions for... CSI Effect Bad Medicine Making Health Care Personal Cashing In GIS for Less Nabbing Speedsters First Person: Records Management Chatter Box Oregon Data Centers Go Green Products Two Cents Spectrum Up Close Personal Computing signal:noise Government Solutions - Spring 2008 Power Play Double Duty Cleaning House Twice Prepared Smart Move The Path to Success Foundation for Service

Government Technology - February 2008

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