February 28th, 2012

Medicare Fraud

I was having a little chat the other day with someone about Medicare fraud. Over the years, it seemed to me that the kinds of things being prosecuted as Medicare fraud were evolving. It seemed maybe there was less of it and it was less egregious. The person I was chatting with felt it was still very common, and generally of the following form: it involved Home Health Care Services and physicians signing off on unnecessary services for patients who maybe should not get any kind of Home Health Care Services at all. What it did _not_ involve were entirely invented patients and generally it did not involve paying people to do things they were not credentialed to do and generally it did not involve charging for services which were not actually rendered.

So it was with some curiosity that I pursued coverage of Jacques Roy in Texas.


I liked this coverage, because embedded in it is a link to a .pdf of the indictment.

Looks like the person I was chatting with was right. I was gobsmacked by a couple of items in the indictment.

"Between January 2006 and November 2011, Medistat certified more Medicare beneficiaries for home health services and had more patients than any other medical practice in the United States."

"... more than 11,000 unique Medicare beneficiaries for home health services provided by over 500 HHAs."

"Medistat and the HHAS billed Medicare for over $350 million and Medicaid for over $24 million for these beneficiaries."

A couple of the other people named ran businesses that got huge fractions (80% for Apple of Your Eye Health Care Services, 78% for Ultimate Care Home Health Services, 79% of Charry Home Care Services) of their business from patients certified by the Medistat doctors.

Another defendant was Medistat's office manager, signing the doctor's name to POCs, and "accepted cash payments ... for ensuring that POCs contained the signature of" one of the Medistat docs.

The indictment is saying _both_ medically unnecessary and not rendered, right down to "Co-conspirator nurses ... would write visit notes to make it appear that they provided skilled nursing to the Recruited Beneficiaries when no skilled nursing was provided." And, "Many of these Medicare beneficiaries had primary care physicians who never certified home healthcare services for them."

This is more or less _exactly_ the fraud the person I was chatting with described to me -- and she doesn't live anywhere near Texas and never has, and she works at the other end of the age spectrum from geriatrics. While this particular operation may have been the largest in the country, I'm hoping that this creates some pressure to Stop Behaving Badly.

Around page 13, a "J.A., Medistat's business manager" is described as having conversations with the Medistat doctor about the business. The word "shady" is used (gotta love that, right?). The details of the business are also quite astonishing. "During the fall of 2010 ... visited The Bridge Homeless Shelter ("The Bridge") in Dallas, Texas to recruit homeless beneficiaries who were staying there ("guests")." Apparently the going rate for a guest with Medicare benefits was $50.

Just in case you're worried that some Heroes providing health care to the Homeless are being picked on, the defendant was "informed, however, by security guards at The Bridge that she was not permitted to treat guests on or near the premises, and that The Bridge had a Parkland Hospital medical clinic inside the gates that was available to the guests."

I'm struggling to understand how I feel about this. Should these guys be prosecuted? Duh. Yes! Hell yes! And then start working down the list of other people doing similar things until the word gets out so that J Random Practical Nurse working in J Random City in J Random State doesn't know this shit is going down everywhere.

One of the rationales for this kind of fraud is to compensate for losses elsewhere to patients who don't have insurance and don't qualify for benefits. But I am pretty _damn_ sure that no such patients were benefiting from this particular scheme. I can understand the motivations behind paper-shuffling, no-violence property crime -- but I'm NOT sympathetic to people who do it for personal enrichment.

Do I think that tackling endemic Medicare (and Medicaid -- but surely you noticed the scale difference between those two numbers) will bend the cost curve "enough"? Not a chance in hell. A buck a person for everyone in the United States today adds up -- but not far enough to address all our health care woes.

But every little bit helps, right?

Usborne Books/EDC no longer selling on Amazon

Here is there press release.

EDC does not have a wikipedia page (and I'm a little unclear on why, altho I have my suspicions -- and yes, I read the copyright infringement explanation).

Usborne Books does have a wikipedia entry:


Here is Nate Hoffelder's mention:


There are some efforts in play to draw a trendline. The first data point is the failure to come to terms between IPG (strictly speaking, a distributor rather than a publisher, but a source of ebooks either way) and Amazon. The second data point is the withdrawal of Usborne (EDC) Books from Amazon. The trend line is, see? Publishers can fight back!

There is a slight problem with this. First, IPG isn't a publisher. But let's ignore that for a moment. Usborne/EDC _is_ a publisher. But Usborne is like Tupperware for books. Tupperware is awesome stuff -- possibly as good or better than any Rubbermaid or anything else you can find for sale at a grocery store or Target or Wal-mart or Costco or whatever. But you can't buy Tupperware in any of those places; you have to buy them from a Direct Sales rep, which is to say, someone who is throwing parties for friends and acquaintance in an effort to generate some funds while having a small amount of fun. [Edited to remove stereotype.]

It's really not at all shocking that a publisher which moves its product through a Direct Sales force would decide that online sales were more of a problem than a benefit.

There are a decent number of third party sellers of Tupperware on Amazon, some of them "Fulfilled by Amazon". One of the comments on Nate's blog suggests that other manufacturer's might switch from listing on Amazon to selling exclusively through their own website. I would argue that we might instead see makers like Tupperware -- who have significant Direct Sales forces -- to require Amazon to delist those products when sold by third parties. But it's hard to be sure exactly how the calculation will play out in any given corporation. More lines to watch would be Amway's Nutrilite products, Avon's Anew, Mary Kay Timewise, Herbalife, etc. -- all of which have third party sellers who are "Fulfilled by Amazon".