1. Bosler, Barbara JD, MHE, RHIA

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To conclude the trilogy of articles on healthcare fraud, Regina R. McCullough, Deputy Chief, Health Care Fraud Unit of the U.S. Department of Justice, U.S. Attorney's Office, Eastern District of Michigan, met with me to offer important insights on healthcare fraud as it relates to Michigan.


Q: Why was the Health Care Fraud Unit established?

Barbara McQuade, U.S. Attorney for the Eastern District of Michigan, established this unit 5 years ago because of the high regard and trust that the public places in healthcare providers, and the known fraud that was and is occurring. The message in establishing this unit is that, "fraud will not be tolerated." The results of the Health Care Fraud Unit clearly show that its work is decreasing the amount of fraud. Providers are posting case articles and press releases of current indictments on their bulletin boards as an alert to themselves and others. Although some providers still fraudulently bill by attempting to "legitimize" past practices, Deputy McCullough's message was clear that, "Providers should stop any illegal practices and measure up to the public's trust in them."


Q: How are cases handled in the Health Care Fraud Unit?

The Health Care Fraud Unit handles two types of cases: Health Care Fraud and Drug Diversion. The Health Care Fraud cases are those where medical necessity criteria for services are billed but not met, and where services were billed but not actually provided.


The Drug Diversion cases are those where there is unlawful diversion of Controlled Substances II-V. This usually involves Medicare patients who are paid by marketers to obtain a prescription from a provider for medications like Oxycodone (oxycontin) and Vicodin. The prescription is written and filled, and the tablets are given to the marketers, who then sell each tablet on the street for $20-30. Collaterally, providers writing unnecessary prescriptions tend to perform and bill for unnecessary diagnostic tests.


Q: Who is the provider who commits fraud?

The providers involved in the recently prosecuted cases are older and have lost money in the stock market or retirement plans. Greed and urgency to make a large amount of money are the motives.


Q: How are healthcare fraud cases identified?

These cases result from medical necessity criteria not being met or services being billed when they were not actually provided. Medical necessity cases are flagged from billing reviews where procedure codes are not supported by the correct diagnosis code. Patients or families often report services billed but not provided by making calls or formal complaints to the Office of Inspector General (OIG). These complaints and coding and billing audits result in broader pattern analyses involving suspicious providers. Medical records are then requested by subpoena or through an executed search warrant.


The first Legal Matters column (Bosler, 2015) talked about the Department of Justice Medicare Strike Force and its important work in combating fraud. The following link demonstrates how this vigilant process of reviewing compliance with medical necessity criteria and diagnosis and procedure validity checks also discussed by Deputy McCullough resulted in the Department of Justice's recent success in a nationwide sweep in 17 districts. The sweep resulted in charges against 243 individuals involving approximately $712 million in false billings: (Department of Justice, 2015).


Q: How are the drug diversion cases identified?

The key to case identification comes from the Code of Federal Regulation, which states that, "The registrant shall design and operate a system to disclose to the registrant suspicious orders of controlled substances. . . Suspicious orders include orders of unusual size, orders deviating substantially from a normal pattern, and orders of unusual frequency." (21 CFR [S]1301.74). It also states that, "A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice," and "The responsibility for the proper prescribing and dispensing of controlled substances is upon the practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription." (21 CFR [S]1306.04(a)).


A nationwide push to incorporate prescription drug monitoring programs resulted in all but two states and the District of Columbia having such a program in place by December 2014 (National Alliance for Model State Drug Laws [NAMSDL]). The Michigan Automated Prescription System (MAPS) is the Michigan monitoring system, which collects and reports Controlled Substance II-V prescriptions dispensed by pharmacies and practitioners (Iwrey, 2012). Providers can query data for patient-specific reports to identify individuals receiving controlled substances from other providers, which prevents prescription drug abuse at the pharmacy, patient, and provider levels. Information about other states can be accessed at (NAMSDL, 2014).


Cases are further identified from tips coming from pharmacists, outside billers seeing trends with scripts not supported by medical necessity, and patient complaints after reviewing a claim or Explanation of Benefit (EOB). Patients and providers operating in different states than their residence or place of business send a flag. Lastly, the U.S. Drug Enforcement Administration has identified a trend with three drug categories prescribed together called the "Holy Trinity": opiates, muscle relaxers, and benzodiazepines. Typically, this group is accompanied with scripts for unrelated medications to obfuscate the "Holy Trinity" pattern. Diagnoses supporting the script are not present. In addition, prescribing providers typically submit accompanying claims with high-level Evaluation and Management codes that also cannot be supported by services provided or time spent with the patient (Holske, 2013).


Q: What steps should providers take when documentation, coding, and billing mistakes are made from ignorance that can be later investigated as fraud?

Deputy McCullough stressed that healthcare providers should review the criteria for each CPT (Current Procedural Terminology) code they use to bill for their services. The Centers for Medicare and Medicaid Services (CMS) has a notable Web site at that includes coding and billing policies and procedures, provider manuals, educational programs, and training materials. Providers should take time to review the materials that correspond to their areas of practice to ensure they are documenting correctly in the medical record (paper and electronic medical record), and coding and billing completely and accurately. Providers making a good faith mistake should contact the OIG and self-report. See Self-report is done by identifying the patient involved with a review of the correct code criteria that should be present when using a particular CPT code. The provider should then identify which code element was not met. The OIG will advise the provider on what steps to take, including amending the medical record and/or claim (OIG).


Q: How can the public help reduce fraudulent activity?

Deputy McCullough offered the following guidelines to consumers, be they a patient and/or family member who accompany a loved-one to a healthcare encounter:


1. Keep a journal of each encounter by date, time waited, time spent in a face-to-face visit with a provider, and provider names. Identify the purpose of each encounter and what was said and done so that the information may be fully recalled at a later time;


2. Ask providers for complete explanations of the diagnosis(es) treated with their recommended plan(s) of care;


3. Be vigilant about reading the EOB and comparing each visit date and service rendered against the journal entries for that episode of care. Call the provider's billing office or the CMS or OIG with any discrepancies;


4. Protect your Medicare card and Social Security Number by keeping your identity safe. Question charges and contact the appropriate government agency about correct billing procedures. The OIG help lines for reporting medical identity theft and fraud are: 1-877-438-4338 and 1-800-447-8477, respectively. CMS Help Desk Support is available at 1-855-326-8366; and


5. Verify the license of the Health Care Facility and Health Provider at the LARA Web site (Licensing and Regulatory Affairs) at,4601,7-154-10401-279163--,00.html to ensure it is current and there are no reported complaints or disciplinary actions.



Advice she reiterated for providers is to take advantage of the assistance provided by CMS at their Web site through webinars, newsletters, and the provider help desk.



Deputy McCullough shared that providers should respect the Hippocratic Oath they took to do no harm to their patients or society, and to uphold ethical principles. Committing fraud by putting patients through unnecessary procedures or making patients think they have serious conditions only to fleece the Medicare program of millions of dollars goes completely against this Oath. It also goes against all the effort and years of training the provider spent to accomplish good for his fellow man. Greed cannot be that strong to make an educated person succumb to this.


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Sponsored by the U.S. COPD Coalition, the observance is a time for organizations and communities across the country to increase the overall awareness of COPD. COPDLearn More Breathe Better(R), the title of the National Heart, Lung, and Blood Institute's national awareness and education campaign, has again been adopted as the theme for this year's National COPD Awareness Month. Chronic obstructive pulmonary disease is the 3rd leading cause of death in the United States. The disease kills more than 120,000 Americans each year-that's 1 death every 4 minutes-and causes serious, long-term disability. The number of people with COPD is increasing. More than 12 million people are diagnosed with COPD and an additional 12 million likely have the disease and don't even know it.

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Bosler B. (2015). Legal matters: Home healthcare and fraud. Home healthcare Now, 23(8). [Context Link]


Code of Federal Regulations. 21 CFR [S]1301.74.


Code of Federal Regulations. 21 CFR [S]1306.04(a).


Department of Justice. (2015). Sixteen charged in Detroit area as part of largest national Medicare fraud takedown in history. Retrieved from[Context Link]


Department of Licensing and Regulatory Affairs. (2015). Michigan Automated Prescription System (MAPS). LARA. Retrieved from,4601,7-154-63294_63303_55478---,00.html


Department of Licensing and Regulatory Affairs. Verify a license. Retrieved from,4601,7-154-10401-279163--,00.html


Holske R. (2013). May 15, 2013 EU-US Dialogue on Drugs:Prescription drug trafficking & abuse trends. Retrieved from[Context Link]


Iwrey R. (2012). What is MAPS and why should I care? Retrieved from[Context Link]


National Alliance for Model State Drug Laws. (2014). Prescription monitoring programs-State law and policy profiles. Retrieved from[Context Link]


Office of Inspector General. (2015). Self-disclosure information. Retrieved from