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Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Diversion and Fraud Related to Prescription Abuse: Case Studies November 10, 2008 South.

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Presentation on theme: "Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Diversion and Fraud Related to Prescription Abuse: Case Studies November 10, 2008 South."— Presentation transcript:

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

2 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 City woman charged with selling drugs Courier-Times Staff Report A 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 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.

3 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

4 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

5 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

6 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Expired Drugs Sold New York Attorney General Andrew M. Cuomo initiated legal action against CVS and Rite Aid pharmacies after a statewide investigation found it had sold expired products, including over-the-counter medications.

7 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

8 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 “DUBAI, United Arab Emirates — Along a seemingly endless row of identical gray warehouses, a lone guard stands watch over a shuttered storage area with 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”

9 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.”

10 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

11 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

12 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 RX Medicare Fraud Initiatives: PBM Perpetrators Prescription drug switching Unlawful remuneration Inappropriate formulary decisions Prescription drug splitting or shorting Failure to offer negotiated prices

13 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

14 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

15 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 RX Medicare Fraud Initiatives: Wholesaler Perpetrators Counterfeit and adulterated drugs through black and grey market purchases Diverters Inappropriate documentation of pricing information

16 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

17 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

18 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

19 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

20 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

21 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

22 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

23 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

24 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

25 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Sample Data Mining Claims Missing Prescriber Identification

26 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Sample Data Mining Claims Missing Prescriber Identification

27 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Sample Data Mining Claims with Irregular (same) Provider Identification

28 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Sample Data Mining Claims with Irregular (same) Provider Identification

29 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Sample Data Mining Beneficiary Abused Meds

30 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Sample Data Mining Beneficiary Abused Meds

31 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

32 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Movement of $, PHI, RX

33 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 All Drugs, Services, Treatment plans at some point require a “patient”

34 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 A patient on Drugs, Receiving Services, or Supplies require a “clinical” record

35 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 SOAP charting as an audit tool “S” Subjective Patient Statement “O” Objective Data “A” Assessment “P” Plan SOAP TEST

36 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 “Who” “What” “When” “Why” “Where” and “How” The 5 W’s & an H

37 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 “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

38 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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

39 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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 Signed Pain Reliever, RN Data Sets

40 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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 Signed Pain Reliever, RN 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 ordered Signed Pain Reliever, RN Janis Doe 1/18/04 9pm “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 Signed Pain Reliever, RN Jake Doe 1/18/04 11pm “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 Signed Pain Reliever, RN

41 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Data Sets – OPS Clinic profile of 4 patients

42 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Data Sets – OPS Clinic profile of 4 patients

43 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 What Else? Sample Counterfeit Medications

44 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Drugs – Packaging Clue

45 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Drugs – Counterfeit Labels

46 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Drugs – Internet Purchase

47 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

48 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

49 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 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.

50 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 This an old cement mixer used to give counterfeit Viagra tablets their blue coloring.

51 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Data Intelligence Models

52 Rebecca Busch, RN, MBA, CCM, CFE, FHFMA MBA Inc. Copyright 2008 Diversion and Fraud Related to Prescription Abuse: Case Studies Rebecca S Busch, RN, MBA, CCM, CFE, FHFMA Contact information: Medical Business Associates, Inc 580 Oakmont Lane, Westmont IL 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 Additionally she is a faculty member of the Association of Certified Fraud Examiners and makes frequent public speaker appearances.


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