Attentive member spots improper charges

After a recent visit to the ophthalmologist, a Blue Cross Blue Shield of Michigan member received her Explanation of Benefit Payments statement and noticed something odd. She saw services listed that she didn't receive. This put up a red flag and she called the Blues Anti-Fraud Hotline number she saw listed on her EOB.

The Blues Corporate and Financial Investigations department did some research and found that this ophthalmologist had been billing improperly for other patients as well. The ophthalmologist was contacted by the Blues, who then refunded the Blues for all of the improperly billed services.

Thanks to a member who not only took the time to review her EOB, but took the extra time to call the Blues, these improper billings were put to a stop.

Not every call to our Anti-Fraud Hotline results in criminal prosecution. Sometimes the call results in the recovery of money that we paid to a health care provider that should not have been paid.

1. What can you, as a patient, do to assure you are billed appropriately?
2. What would you do if you found charges on your EOB or bill that you don't believe was a service you had?

Case 2

Parkview will pay $800,000 and adopt a corrective action plan to address deficiencies in its HIPAA compliance program. Parkview is a nonprofit health care system that provides community-based health care services to individuals in northeast Indiana and northwest Ohio.

Department of Health and Human Services Office for Civil Rights (OCR) opened an investigation after receiving a complaint from a retiring physician alleging that Parkview had violated the HIPAA Privacy Rule. In September 2008, Parkview took custody of medical records pertaining to approximately 5,000 to 8,000 patients while assisting the retiring physician to transition her patients to new providers, and while considering the possibility of purchasing some of the physician's practice. On June 4, 2009, Parkview employees, with notice that the physician was not at home, left 71 cardboard boxes of these medical records unattended and accessible to unauthorized persons on the driveway of the physician's home, within 20 feet of the public road and a short distance away from a heavily trafficked public shopping venue.

1. What should have happened with the transfer of records from the retiring physician to the new clinic?
2. How should the records have been returned to the retiring physician?

Case 3

Ohio physician convicted of health care fraud and theft

She was trying to amass the riches of a queen, but Dr. Stacey Royal ended up being the court jester.

The Ohio Department of Insurance contacted Blue Cross Blue Shield of Michigan's Corporate Fraud and Investigations department about Dr. Stacey Royal, who ran the Royal Treatment Urgent Care in Perrysburg, Ohio. Dr. Royal was being investigated for billing for services not rendered on health care contracts of her family and friends without their knowledge. She had filed more than $900,000 in false claims to insurance companies, including approximately $135,000 to BCBSM.

The investigation initially identified false claims being submitted to Anthem Blue Cross Blue Shield of Ohio for BCBSM members. To prevent further losses, BCBSM investigators initiated a fraud alert to other Blue Cross plans, which prevented additional payments of more than $1 million in fraudulent claims submitted for BCBSM members.

Royal's trial began on Sept. 13, 2010. Investigators from BCBSM testified during the trial about the losses incurred as a result of Dr. Royal's scheme to defraud. Other testimony in the trial included a doctor who performed a surgical procedure that Dr. Royal observed for educational purposes. She then proceeded to submit a claim for performing the procedure, and her claim was for more than the amount the actual surgeon billed. On Sept. 16, 2010, Dr. Royal pleaded guilty to four counts each of insurance fraud and theft, two counts of telecommunications fraud and one count of engaging in a pattern of corrupt activity. She was sentenced to five years probation and full restitution to all victims.

Royal's boyfriend, Christopher Davis, also employed at the Royal Treatment Urgent Care, was also convicted of complicity to insurance fraud, complicity to theft and engaging in a pattern of corrupt activity. He was sentenced to 180 days in jail, one year probation and ordered to pay $100,497.59 in restitution to BCBSM for false claims on his personal insurance coverage.

1.As the biller, how could you determine if she was observing versus performing surgeries she was billing for?

2.As a patient, how could you determine if she was observing versus performing the billed surgery?

3.If she wrote off any patient balance after insurance paid, how could you, as the patient, ever detect this?

Case 4

Employee embezzles reimbursement checks at Adrian dental clinic

An employee of an Adrian dental clinic was found to have defrauded both her employer and BCBSM. The woman was discovered to be embezzling insurance reimbursement checks sent to the office. She manipulated the computer system so the patient accounts appeared balanced and the missing money was not noticed. The dental clinic learned of the embezzlement from the bank where the employee was depositing the checks into a personal account through the ATM machine. The Sheriff's Department contacted BCBSM Corporate and Financial Investigations because several of the checks were issued by BCBSM.

Further investigation revealed that not only had this employee embezzled from the dental clinic, but she had submitted false claims to BCBSM for dental services supposedly rendered to her family members. The employee created the false claims in the clinic's computer system, and made the claim payable to the subscriber, so checks were issued to her home address. The woman had created claims for crowns, X-rays and mouth guards for family members. Additional research revealed that the employee had conducted the same scheme when previously employed at another dental clinic.

The woman was charged in Lenawee County with Embezzlement, Health Care Fraud, Forgery and Uttering and Publishing a Financial Transaction Device. She pled guilty and was ordered to pay full restitution to the dental clinic and BCBSM. The defendant will re-pay BCBSM $14,923.56 and her (now former) employer $9,566.19.

1. As the employer, how could this have been prevented? Be as specific as possible.

Case 5

A group of nurses began using Facebook to provide unauthorized shift change updates to their coworkers.They did not use patient names, but they did post enough specifics about patients so that the incoming nurses could prepare for their shift.

1. Was HIPAA violated? Why or Why not? Be as specific as possible.