rebecca busch, rn, mba, ccm, cfe, fhfma mba inc. copyright 2008 diversion and fraud related to...

Rebecca Busch, RN, MBA, CCM, CFE, FHFMAMBA Inc. Copyright 2008

Diversion and Fraud Related to Prescription Abuse: Case Studies

November 10, 2008

South Portland, ME

Rebecca S Busch, RN, MBA, CCM, CFE, FHFMA


City woman charged with selling drugs Courier-Times Staff ReportA woman from New Castle is accused of illegally selling two prescription drugs to an undercover buyer.

Margaret A. Kern, 48, appeared in court on Wednesday after her arrest on Tuesday. Charges filed on Oct. 22 allege dealing in a Schedule 2 controlled substance, Class A felony, dealing in a Schedule 4 controlled substance, Class B felony, and maintaining a common nuisance, Class D felony.

The alleged drug deal happened at Beckford Place Apartments, 2900 S. Memorial Drive, Apt. 403, New Castle. Reportedly, the buyer exchanged cash for hydrocodone and alprazolam pills in early 2008. Hydrocodone is a painkiller and alprazolam is an anti-anxiety medication.

The dealing charges leveled against Kern were upgraded from Class B and C felonies because they happened in an apartment complex. A pretrial conference is set for Jan. 26, and a jury trial is scheduled for March 2. A public defender has been appointed to represent Kern.


More than 50 arrests made in "Operation Bad Medicine"

St. Lucie County Sheriff Mascara announces 53 arrests in three-month "Operation Bad Medicine."

A three-month St. Lucie County Sheriff's Office investigation into prescription fraud, doctor shopping and illegal sales of prescription drugs has resulted in 53 arrests for a total of 98 charges and the seizure of more than 3,000 pills, according to Sheriff Ken J. Mascara.


Doc arrested in Mobile, Ala., child abuse case lost license to practice medicine over use of drugs

A former doctor accused of abusing an 8-month-old lost his medical license six years ago after regulators accused him of using his position to feed a prescription-drug habit.

When the Alabama Board of Medical Examiners finished investigating Dr. David Dodd Ozment in April 2002, it immediately suspended his license, saying that his continued practice constituted an "immediate danger to patients and the public."

The revocation was only temporary, pending a full hearing on the matter, but Ozment voluntarily surrendered his license two months later, and the board dropped its complaint, according to board documents.

Ozment, 41, was arrested Tuesday and charged with willful abuse of a child and practicing medicine without a license.

Police said an 8-month-old boy Ozment was baby-sitting suffered third-degree burns caused by hot water in a bathtub. The boy also had bruises on his face and body, police said.

Mobile police spokesman Sgt. Marcus Young said Ozment had been giving the child medical treatment out of his home for months.

Investigators are still trying to find out if Ozment had other patients as well. He was released on $3,500 bail Tuesday night. Attempts by the Press-Register to contact

him were unsuccessful. According to the findings by the Alabama Board of Medical Examiners' investigation,

Ozment: Filled 460 prescriptions, predominantly for controlled substances, for himself during a period of two years. Forty-three of those prescriptions were filled during one month at a single pharmacy.


Two men convicted in pharmacy burglary conspiracy- EAST ST. LOUIS --

• A federal jury in East St. Louis convicted two West Virginia men Wednesday in connection with the burglaries of about 85 pharmacies in 10 states, including Southern Illinois.

• The jury also returned special verdicts finding that four deaths resulted from the drug-trafficking scheme of Rex. I. Hatfield, 52, and his brother, Everly K. Hatfield, 48, both of Oceana. Because of this, the two face up to life in prison when they are sentenced Jan. 30.

• The Hatfields were convicted of conspiracy to commit pharmacy burglaries and conspiracy to distribute controlled substances, according to information released by the U.S. attorney's office.

• More than 100 witnesses testified in the nearly monthlong trial, which was prosecuted by assistant U.S. attorneys Robert L. Garrison and Nicole E. Gorovsky.

• According to testimony, the Hatfields headed a group that committed the burglaries, a dozen of which occurred in Southern Illinois communities including Flora, Eldorado, Fairfield, Mattoon, Metropolis and Carmi, and five of which occurred in Missouri communities including St. Charles, Crestwood, Seneca and St. Joseph.

• Between 1998 and 2004, the group stole more than $500,000 worth of controlled substances, such as Oxycontin pills and morphine patches. The Hatfield transported the stolen pharmaceuticals to West Virginia and Virginia and sold them to drug traffickers working for them, according to testimony in the case.

• The jury determined the Hatfield's scheme resulted in four deaths, including the 2001 death of Deborah Smith in Honaker, Va. and the 2002 death of Carol Walker in Glen Fork, W.Va. Witnesses testified the brothers suspected the two women of being police informants and had bragged after the two died, claiming they had prevented them from testifying, according to information released by the U.S. Attorney's Office.

• Jurors also found the brothers responsible for the drug-related, life-threatening injuries to a Glen White, W.Va., man who they believed planned to testify against them. When the man collapsed and stopped breathing after a drug injection, Everly Hatfield said, "Let him die. Don't revive him," according to testimony.

• The case against the Hatfields was investigated over a four-year period by agents of the federal Drug Enforcement Administration and federal Bureau of Alcohol, Tobacco, Firearms and Explosives and investigators of the Madison County Sheriff's Department, Russell County, Va., Sheriff's Department and Oceana Police Department.


Expired Drugs Sold

• New York Attorney General Andrew M. Cuomo initiated legalaction against CVS and Rite Aid pharmacies after a statewide investigation found it had sold expired products, including over-the-counter medications.


Prescription drugs growing problem in community

The AHEAD coalition has tried to provide information and support to one mother who is trying to keep her adult daughter from getting Vicodin prescriptions because she is abusing that medication. We heard from another parent who is concerned about how prescriptions are being locked up in her child’s friends’homes because her son is drug-seeking.


• “DUBAI, United Arab Emirates — Along a seemingly endless row of identical gray warehouses, a lone guard stands watch over a shuttered storage areawith a peeling green and yellow sign: Euro Gulf Trading.”

“Three months ago, when the authorities announced that they had seized a large cache of counterfeit drugs from Euro Gulf’s warehouse deep inside a sprawling free trade zone here, they gave no hint of the raid’s global significance.”

“Free trade zones allow counterfeiters to evade the laws of the country”


British customs officials made a troubling discovery at Heathrow Airport in London.

“They intercepted 846 pounds of pharmaceuticals, mostly counterfeits of products made by such well-known companies as Merck, Novartis, AstraZeneca, Pfizer and Procter & Gamble. Some medication contained traces of metal.”


RX Medicare Fraud Initiatives: Plan Sponsor Perpetrators

• Failure to provide medically necessary services• Marketing Schemes• Improper bid submissions• Payments for excluded drugs• Multiple billing• Non-Compendium Payments • Inappropriate formulary decisions• Inappropriate Enrollment/Disenrollment• Appeals process handled incorrectly• Adverse Selection• False information


RX Medicare Fraud Initiatives: Plan Sponsor Perpetrators

• Delinquent reimbursements• Duplicative premiums• Excessive premiums• Inaccuracies in eligibility or coordination of benefits• Incorrect calculation of TrOOP• Inaccurate data submission• Catastrophic coverage manipulation• Failure to disclose or misrepresentation of rebates,

discounts or price• Bait and switch pricing• Manipulation of low-income subsidy enrollees


RX Medicare Fraud Initiatives: PBM Perpetrators

• Prescription drug switching

• Unlawful remuneration

• Inappropriate formulary decisions

• Prescription drug splitting or shorting

• Failure to offer negotiated prices


RX Medicare Fraud Initiatives: Pharmacy Perpetrators

• Inappropriate billing practices• Prescription drug shorting• Bait and switch pricing• Prescription forging or altering• Dispensing expired or adulterated prescription

drugs• Prescription refill errors• Illegal remuneration schemes• TrOOP manipulation• Failure to offer negotiated prices


RX Medicare Fraud Initiatives: Prescriber Perpetrators

• Illegal remuneration schemes

• Prescription drug switching

• Script mills

• Provision of false information

• Theft of prescriber’s DEA number or prescription pad


RX Medicare Fraud Initiatives: Wholesaler Perpetrators

• Counterfeit and adulterated drugs through black and grey market purchases

• Diverters

• Inappropriate documentation of pricing information


RX Medicare Fraud Initiatives: Pharmaceutical Perpetrators

• Lack of integrity of data to establish payment and/or determine reimbursement

• Kickbacks, inducements and other illegal remuneration

• Formulary and formulary support services

• Inappropriate relationships with physicians

• Illegal off-label promotion

• Illegal usage of free samples


RX Medicare Fraud Initiatives: Medicare Beneficiary Perpetrators

• Misrepresentations of status• Identity theft• TrOOP manipulation• Prescription forging or altering• Prescription diversion and inappropriate use• Resale of drugs on black market• Prescription stockpiling• Doctor shopping• Improper Coordination of Benefits• Marketing Schemes


Private and Public Payers


3rd Party Service Providers

3rd Party Service Providers

Healthcare Providers

Healthcare Providers

White Collar and Organized CrimeWhite Collar and Organized Crime

Plan Sponsors

Government

Employer

Office of Personnel

Management

Patients

Insured

Employee

Gov. Employee

Solvent Uninsured

Insolvent Uninsured

$ and PHI

MBA consulting

andaudit work

Healthcare Continuum Chart

Movement of $, PHI, RX



(TPA)


(TPA)

PBMPBM

PharmacyPharmacy

White Collar and Organized CrimeWhite Collar and Organized Crime

Plan Sponsors

Government

Employer

Office of Personnel

Management

Patients

Insured

Employee

Gov. Employee

Solvent Uninsured

Insolvent Uninsured

MBA consulting

andaudit work

PBM Continuum Chart

ManufacturerManufacturer

WholesalerWholesaler

BrokerBroker



PBM Operational Pipeline Chart

Insured Patient

Health Plan

PBM

Pharmacy

Broker

TPA

Pharmaceutical Wholesaler

Pharmaceutical Manufacturer

Recipient of Drug, premium payments to the health plan, cost sharing by paying Pharmacy out of pocket

$

$ Provides Rx benefits to a group, premium/cost payments to the TPA. Recipient of applicable rebates

Provide benefit plan design, may be compensated by health plan, TPA, and or PBM

TPA collects funds from health plan, pays PBM, may be paid by PBM for services

PBM provides payment to Pharmacy for drug costs, receives price discounts for insured patients.

Provides discounts to PBM, receives payments from PBM, provides drug to patient

$

$

$ - money exchange

D – Discounted Price

DP- Discounted Product

R – Rebates

P- Product

DDP

R

R

Sell Products

$

P

$

Audits in the following areas: HIP – Health information audits; ARP- Accounts

Receivable & Fee schedule Audits: OFA – operational flow

assessments & internal controls

TPA Contract

Yes

Plan Sponsor Contract

PBM Contract

Rx Contracts



ACCOUNTS RECEIVABLE PIPELINE: Operational ACCOUNTS RECEIVABLE PIPELINE: Operational Flow Activity (OFA) (Product Market Activity)Flow Activity (OFA) (Product Market Activity)

HCC: Others: Pharmaceuticals

HIP; ARP; OFA; PMA; SMA; CMA

Flows

Drug market activity: sample

application

HCC: Others: Pharmaceuticals

HIP; ARP; OFA; PMA; SMA; CMA

Flows

Drug market activity: sample

application

Drug Research

FDA Approvals

Drug Manufacture- foreign vs. domestic

Drug (re) Distribution primary wholesale

Drug (re) Distribution – retail domestic & foreign: Physicians…Pharmacies…PBMs, Facility Based

Care (licensed facility, pharmacists, physicians)

Research, Regulatory/Gov Requirements, Compliance, Distribution, Packaging, Wholesale, Retail:

Requirements & Standards

Drug (re) Distribution secondary wholesale

(re) Packaging

(re) Packaging

Contemporaneous, cyclical, recurring activity – create weak links

Layered Operational flow activity, complex contracts $ flows, approved relationships

Contractual arrangements



ACCOUNTS RECEIVABLE PIPELINE : Operational ACCOUNTS RECEIVABLE PIPELINE : Operational

Flow Activity (OFA) (ILLICIT Market Activity)Flow Activity (OFA) (ILLICIT Market Activity)Service market activity: sample

application

Service market activity: sample

applicationIllness, Wellness, & Support Health Services

Research

FDA & Regulatory Approvals & Licenses

Service Developers - foreign vs. domestic

Service (re) Production, Provision, & Distribution

primary wholesale

Service (re) Production, Provision, & Distribution – retail domestic & foreign: Physicians…Pharmacies…PBMs...Facility Based Care

(licensed facility, pharmacists, physicians)

Research, Regulatory/Gov Requirements, Compliance, Distribution, Packaging, Wholesale, Retail, Marketing

& Sales: Requirements & Standards

Service (re) Production, Provision, & Distribution secondary wholesale

(re) Packaging

(re) Packaging

Manipulations of service & pricing; illicit distributions;

introduction of altered service, quackery, substandard care,

counterfeit

Medically unnecessary Production, Provision,

& distribution

False Research; unlicensed;

noncompliance

Marketing & Sales Misrepresentations throughout

Benefit Plan Manipulations; false claims;

vendor, employee,

corporate fraud; organized crime;

kickbacks

Waste, fraud, abuse



EOB (Explanation of Benefits)

Provider Bill Submitted to TPA

PPO Network processing, if applicable

Adjudication

Provider Processing/Follow Ups

•Audits/ investigations

•Eligibility of claimant

•Eligibility of charges

•Calculate benefit

•Apply appropriate deductions, co-insurance

•Verify maximum limits

•Process check or denial

•Other Audits/ Reviews








•Other Audits/ Reviews

Plan document verification

Employer Processing/Follow UpsTPA Reports

Disbursement/ Payment

(Employer Fund)

(Payer Fund)

(HIP) What electronic claims system is being utilized? Do they have a SAS 70 report? Did you read it? (ARP) What are the financial terms & fee schedules? (OFA) How is clinical data managed versus financial?

(HIP) How many providers do they have under contract? (ARP) What percentage of claims are being paid within and out of network? (OFA) How are these claims paid and processes?

(HIP) What management reports are used for tracking claims? (ARP) What internal controls are in place to verify contractual guarantees? (OFA) How can it be audited and corroborated?

(HIP) How are false claims investigated? (ARP) What were the actual results from the prior year? (OFA) What procedures are used for False Claim Activity?

Payer Operational Pipeline Chart

PBM



Sample Data MiningClaims Missing Prescriber Identification

Query: Medications dispensed without a recorded prescriberidentification

Result: Several occurrences discovered in which pharmaciesdispensed medication without recording prescriberidentification.

Deficiency: The table in Appendix 41 indicates 27 incidences wherepharmacies dispensed medication without recordingprescriber identification. The amount of money spent onthese claims totals $xx,xxx.xx.

Corrective Action Taken By Management:

Will meet with PBM and RX. Findings will be reported Junexxxx.

Internal Controls

Suggestion: Evaluate internal controls for dispensing medications withouta prescriber ID.

Management Response:


Sample Test


Sample Data MiningClaims Missing Prescriber Identification


Sample Data Mining

Claims with Irregular (same) Provider Identification

Query: Medications dispensed with a recorded prescriberidentification attributed to multiple prescriber last names

Result: Numerous occurrences discovered in which pharmaciesdispensed medication with a recorded prescriber identificationattributed to prescribers with different last names.

Deficiency: The table in Appendix 42 indicates 495 incidences wherepharmacies dispensed medication with a recorded prescriberidentification attributed to prescribers with different lastnames. The amount of money spent on these claims totals$85,931.64.

Corrective Action Taken ByManagement:


Internal Controls

Suggestion: Evaluate internal controls for dispensing medications fromproviders who are sharing the name ID. Discussing andrequesting PBM’s controls is appropriate.

Management Response: This is the mail-in program as verified 3/24/xx, hence thesame ID used to signify mail-in. Will meet with PBM and RX.Findings will be reported June xxxx.

Sample Test


Sample Data Mining

Claims with Irregular (same) Provider Identification


Sample Data MiningBeneficiary Abused Meds

Query: Top 20 medication use (by dollar amount)Result: Applicable amounts are indicated in Appendix 34.

Observation: High profile medications susceptible to abuse arehighlighted in the table below.

Suggestion: Clarify vendor surveillance activity. Internal Controls

Management Response:

RX to see if proper protocol established for thesehigh profile medications to monitor abuse or overdispensing. Will meet with XXXX May 9th forproper protocol. Will forward findings by end ofJune XXXX.

Sample Test


Sample Data MiningBeneficiary Abused Meds

Sample Data

Product Service Description

Usual & Customary Amount Ingredient Cost Submitted

Pharmacy Submitted

Amount Ingredient CostDispensing

FeeTotal Sales

Tax Gross CostClient

Amount Due

Ingredient Cost

Difference Amount

Patient Paid Amount

NEXIUM $171,542.03 $169,144.59 $172,742.83 $156,839.02 $787.77 $1,309.30 $158,936.09 $143,119.84 ($12,253.60) $15,816.25 LIPITOR $117,460.88 $116,711.24 $119,100.23 $107,795.46 $872.28 $1,281.34 $109,949.08 $97,286.33 ($8,886.88) $12,662.75 SINGULAIR $67,306.35 $64,574.54 $66,859.77 $57,801.00 $635.85 $683.87 $59,120.72 $50,576.03 ($6,736.09) $8,544.69 HYDROCODONE-ACETAMINOP $66,378.77 $56,846.10 $66,289.34 $32,955.96 $3,532.68 $440.78 $36,929.42 $18,934.48 ($31,481.78) $17,994.94 ADVAIR DISKUS $66,288.23 $65,781.03 $66,417.56 $60,447.78 $297.45 $355.00 $61,100.23 $53,951.73 ($5,490.37) $7,148.50 CYMBALTA $66,102.19 $64,028.01 $66,072.15 $56,410.78 $600.39 $764.21 $57,775.38 $49,047.67 ($7,419.35) $8,727.71 LEXAPRO $64,234.86 $61,144.04 $63,574.57 $56,935.04 $859.59 $894.68 $58,689.31 $40,967.69 ($11,184.93) $17,721.62 VYTORIN $63,440.84 $61,906.85 $64,274.64 $56,328.00 $620.82 $901.81 $57,850.63 $49,721.84 ($5,469.50) $8,128.79 EFFEXOR XR $63,209.87 $60,843.46 $62,569.89 $55,485.30 $444.78 $761.08 $56,691.16 $46,923.86 ($9,254.41) $9,767.30 ZYRTEC $52,812.89 $48,716.57 $50,780.47 $43,617.56 $801.45 $661.23 $45,080.24 $35,315.95 ($5,515.16) $9,764.29 CELEBREX $52,785.01 $51,726.93 $53,235.50 $46,816.47 $450.00 $696.76 $47,963.23 $41,123.93 ($4,905.22) $6,839.30 PREVACID $52,311.45 $51,591.23 $52,371.15 $48,147.85 $319.86 $529.68 $48,997.39 $41,624.72 ($8,342.19) $7,372.67 ADDERALL XR $52,074.20 $47,492.43 $50,378.58 $40,662.84 $507.96 $1,153.78 $42,324.58 $35,207.10 ($6,489.89) $7,117.48 ACTOS $51,835.44 $50,940.25 $52,847.81 $47,069.19 $226.53 $317.53 $47,613.25 $43,827.95 ($3,946.10) $3,785.30 SIMVASTATIN $51,221.05 $63,401.72 $58,839.70 $39,871.84 $529.65 $318.91 $40,720.40 $35,923.12 $27,774.63 $4,797.28 OXYCONTIN $49,698.18 $49,574.14 $49,955.11 $41,976.92 $100.89 $211.40 $42,289.21 $34,147.46 ($7,244.84) $8,141.75 NEXAVAR $49,111.33 $49,093.20 $49,111.33 $49,093.20 $18.13 $0.00 $49,111.33 $45,840.53 $0.00 $3,270.80 PLAVIX $48,184.41 $48,432.10 $49,431.29 $44,185.19 $352.44 $571.92 $45,109.55 $39,983.29 ($3,217.64) $5,126.26 LEVAQUIN $44,732.47 $42,538.79 $44,050.46 $35,660.16 $617.40 $581.73 $36,859.29 $29,129.67 ($6,700.46) $7,729.62 AZITHROMYCIN $43,221.47 $41,699.61 $45,536.15 $26,443.91 $1,629.00 $584.19 $28,657.10 $19,843.60 ($20,426.42) $8,813.50


EOB (Explanation of Benefits)

Contract with TPA

Implement contracted Terms: Set up controls for monitoring terms.

Vendor audits

TPA Processing/Follow Ups








•Verify TPA Fees

•Conduct QA Audits

•Verify Internal controls

•Verify Employee Internal controls








•Verify TPA Fees

•Conduct QA Audits

•Verify Internal controls

•Verify Employee Internal controls

Plan document verification/audit/monitoring

Employer Processing/Follow Ups

TPA Reports

Disbursement/ Payment

(Employer Fund)

(Payer Fund)

(HIP) Collect all signed contracts & identify all parties involved. Look for non contracted parties. (ARP) Identify all $ schedules within each contract. (OFA) How can the information be corroborated?

(HIP) Review Right to Audit Provisions (ARP) What $ transaction cannot be audited or corroborated? (OFA) How can the information be corroborated?

(HIP) Collect reports that demonstrate adjudication according to the plan document. (ARP) Identify claims not paid according to plan. (OFA) What internal controls are in place?

(HIP) Collect information on management reports for adjudication activity (ARP) reconcile bank statements with fees. (OFA) What internal controls are in place?

Plan Sponsor Operational Pipeline Chart

PBM



Bills printed

Patient discontinues use of product or service

Bill submitted to TPA/ Payer for processing

Pre-Admission/Admission/Office Appointment (identify parties involved in reimbursement of item or service

ordered)

Product or Service utilized by the patient

Ordering professional documents effects of products or services & process billor professional component. Supplier submits a bill for product or service

Payment Received Account follow-up/Collection

Service or Product ordered by an MD, DC, DO or facility based provider for a patient

Manufacturer Drug Distribution

Collect both operational and patient records at each operational function

HIP: Identify Patient Profiles ARP: Review Facility Cost ReportsOFA: Business flow & use of Drugs PMA: Cancer Drug SMA: Review clinical staff CMA: Why did the patient choose that provider?

Product, Service, Consumer Market Pipeline Chart

PBM



All Drugs, Services, Treatment plans at some point require a “patient”


A patient on Drugs, Receiving Services, or Supplies require a “clinical” record


SOAP charting as an audit tool

“S” Subjective Patient Statement

“O” Objective Data

“A” Assessment

“P” Plan

SOAP TEST


“Who”

“What”

“When”

“Why”

“Where” and

“How”

The 5 W’s & an H


“Who” Staff Nurse on pm shift

“What” High rate of overcharges on patient bills

“When” credits noted on pm and night shift

“Why” ?

“Where” Unit 10 South

Case History


Jane Doe 1/16/04 9pm“S” C/O Pain 8/10“O” Percocet given 2 tabs 10pm“A” Pain secondary to surgery“P” Give meds as ordered

Signed Pain Reliever, RN

Data Sets


Jane Doe 1/17/04 9pm“S” c/o pain 5/10 “O” Percocet given 2 tabs at

2pm pain 8/10 medicated with relief

“A” Pain secondary to surgery“P” Gave dose at 9pm


Data Sets


Jane Doe: 1/18/04 8pm

“S” C/O Pain 8/10“O” Percocet given 2 tabs 10pm

VSS b/p 134/72 HR 86 RR 22“A” Pain secondary to surgery“P” Give meds as ordered


Data Sets – OPS Clinic profile of 4

patients

John Doe 1/18/04 10pm

“S” C/O Pain 8/10“O” Percocet given 2 tabs

10pm VSS b/p 134/72 HR 86 RR 22

“A” Pain secondary to surgery

“P” Give meds as orderedSigned Pain Reliever, RN

Janis Doe 1/18/04 9pm


10pm VSS b/p 134/72 HR 86 RR 22



Jake Doe 1/18/04 11pm


10pm VSS b/p 134/72 HR 86 RR 22





patients

SOAP ANALYSISS O A P Time Patient Staff QA SC PS A

1/16/20041/17/20041/18/20041/18/20041/18/20041/18/2004TOTAL

QA- Quality of CareSC- Substandard of CarePS - Patient SafetyA - Anomaly



patientsSOAP ANALYSIS

S O A P Time Patient Staff QA SC PS A1/16/2004 1 1 1 1 9pm JANE PR X X X1/17/2004 1 1 1 1 9pm JANE OC1/18/2004 1 1 1 1 8pm JANE PR X X X X1/18/2004 1 1 1 1 9pm JANIS PR X X X X1/18/2004 1 1 1 1 10pm JOHN PR X X X X1/18/2004 1 1 1 1 11pm JAKE PR X X X XTOTAL 6 6 6 6

% 100% 100% 100% 100%

QA- Quality of CareSC- Substandard of CarePS - Patient SafetyA - Anomaly


What Else?

Sample Counterfeit Medications


Drugs – Packaging Clue


Drugs – Counterfeit Labels


Drugs – Internet Purchase


Sample: Ponstan

Although similar in appearance to the authentic tablets, the counterfeit Ponstan tablet on the left contains no active ingredient.

Instead, it is composed of boric acid, brick dust and paint. Boric Acid is a pesticide that can cause gastrointestinal and renal failure.


Columbian authorities raided this manufacturing site where they found more than 800,000 counterfeit Ponstan tablets, as well as large quantities of Terramycin, packaging for both products, and manufacturing equipment.

The counterfeit Lipitor tablets on the left are nearly identical from the authentic tablets on the right. Only distinguishable to the consumer by their bitter taste, the counterfeit tablets were among more than 18 million counterfeit Lipitor tablets removed from the U.S. supply chain in 2003.


Sample: Viagra

This is a Viagra counterfeiting site in Egypt. Counterfeit tablets were being given their blue coloring using an old cement mixer. Clearly, the manufacturing conditions were far from sterile.


This an old cement mixer used to give counterfeit Viagra tablets their blue coloring.


Macro & Micro Perspective of MBA’s Anomaly Tracking Model

Anomaly, Detect, Investigate, Mitigate, Prevent, Respond, Recover

Macro & Micro Perspective of MBA’s Anomaly Tracking Model

Anomaly, Detect, Investigate, Mitigate, Prevent, Respond, Recover

Data

Query

HIP Data: Indirect & Direct Patient

CMA Activity

(CPT & ICD)

OFA Controls

PMA

SMA

$ ARP Issues

Vendor Relationships

Anomaly impacting recovery

(output)

Anomaly Continuum

Anomaly New & Old

Tables

Theory

Detection Investigation

Mitigation Prevention

Response Recovery New & Old

Patterns

EDA Activity: tips, data variances, predication, evidence,

settlement, damage control, Internal Controls, Audits, market demands, retribution, compensation, contribution

Market Response:

Industry Standards

Compliance Legislation

Litigation

Criminal, Civil, CIA’s,

Settlements

(output)

Data Intelligence Models


Diversion and Fraud Related to Prescription Abuse: Case Studies

Rebecca S Busch, RN, MBA, CCM, CFE, FHFMA

Contact information: [email protected]

Medical Business Associates, Inc

580 Oakmont Lane, Westmont IL 60559

www.mbanews.com

In 1991, Rebecca founded Medical Business Associates with the vision of delivering a multi-disciplined approach to conducting comprehensive audits for patients, employers, providers, healthcare vendors and insurance companies. Her proprietary methodology employs statistical analysis of claims and procedural data specifically targeted to identify the most probable areas of operational breakdowns, exposure to fraud, financial errors, medical errors, and cost savings. Ms. Busch’s ability to quickly identify anomalies from vast amounts of data has distinguished her and Medical Business Associates as an invaluable source enabling dramatic cost-savings for clients. In addition, Ms. Busch testifies as an expert in the area of health care reimbursement, internal controls, life care expense analysis, patient care documentation and respective damages – and she has authored “Healthcare Fraud: Audit and Detection Guide” (Wiley Publications 2007) and “Electronic Health Records: An Internal Audit Guide” (Wiley Publications 2008); and a “how to” book that will teach American families how to prevent medical errors and detect fraud in reviewing their own families’ medical records through MBA’s electronic personal health record, PortFoliasm. Selective case study contributions may also be found in “Computer Case Fraud Book Bytes that Bite” edited Joseph T. Wells (editor) “I Do” Case study on Identity Theft by Rebecca Busch (contributing author) John Wiley & Sons, Inc. (2008) and “Fraud Casebook: Lessons from the Bad Side of Business” Joseph T. Wells (editor), Chapter 59 “Bodies for Rent” by Rebecca Busch, Wiley & Sons Publications, July 2007. Additionally she is a faculty member of the Association of Certified Fraud Examiners and makes frequent public speaker

appearances.

rebecca busch, rn, mba, ccm, cfe, fhfma mba inc. copyright 2008 diversion and fraud related to...

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