Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

Recently, there has been an unbelievable amount of bandwidth spent discussing telemedicine as it relates to DME and mail order pharmacy.  Most interestingly (to me at least), is the fact that everyone seems to be discussing “what you can do to protect yourself” if the government comes knocking.  It seems counterintuitive to me that people need to be educated as to what they would need to do (at least prospectively) to protect themselves from legal liabilities when they are engaged in fraudulent behavior in the first place. Telemedicine is clearly taking a strong foothold in the healthcare reimbursement world.  We hear frequently about the increased use of telemedicine and expanded coverage for such treatment models.  I agree – it is part of the evolution of modern healthcare.  At the same time, those that are seeking to financially benefit themselves on the backs of taxpayers, the Medicare program and commercial insurance, have no interest in furthering or modernizing healthcare.

As press releases, news accounts, and my personal experiences have demonstrated, the lack of a doctor-patient relationship, the de-minimus relationships that are established through the use of an otherwise absurd questionnaire developed to do nothing more than identify the “good patients from the bad patients,” and the use of off-shore telemarketing “boiler rooms,” demonstrates that those bent on defrauding the healthcare industry do not have patient care as the focus.  I recall doing an investigation relating to a mail-order pharmacy where the Medicare beneficiary I interviewed showed me several boxes of a topical pain medication that they were receiving from a pharmacy they had never heard of, with the prescribing doctor being someone they did not know.  As it evolved, I learned that the beneficiary had gone to a health fair in their community, was solicited for a “free” health screening that was conducted by some unknown person who did nothing more than take their blood pressure and ask a few basic health questions.  Unfortunately for this Medicare beneficiary, that was the beginning of the end with respect to the barrage of monthly mailings of a topical medication for pain that the beneficiary did not have.

The volume of press releases, alerts and messages can be overwhelming to a population of people who understand and can digest the information, and more so to those who can’t.  My elderly parents are not technologically literate, and I am sure none of the warning messages are making their way to them.  So, what is the answer?  It will always be data analytics.  Although data is not the end answer to everything, it can be a very powerful tool in identifying the existence of a doctor-patient relationship, prior diagnoses that would facilitate a need for the medication prescribed, geographical considerations, and a host of other data points that can be used to stop money from going out the door.

I remember speaking to one pharmacy benefit manager (PBM) about data and the submission of claims.  The PBM had sent a cease and desist letter to a pharmacy for violating the contract indicating that the pharmacy would not ship medication to plan members that were out of state to the pharmacy.  The pharmacy had in fact been doing that, and with receipt of the cease and desist letter, agreed to stop the practice.  Guess what?  Merely a couple of months later, the pharmacy continued the practice.  When I asked the PBM about how it was that the pharmacy was not terminated for the repeated violation, even after acknowledging it had occurred and created a corrective action plan, the PBM noted that it did not do any monitoring to ensure compliance.

Data.  The Strike Force model relies on it.  It has proven success when combined with human intelligence to interpret and direct how the data should be used and ingested.  In the end, is it really a matter of “what can you do to protect yourself” if the government comes knocking, or is it a matter of knowing that there will always be unscrupulous providers of healthcare services, and all those involved in healthcare fraud enforcement will always have a successful career?