Tag team is winning formula for fraud bills

Legislative_signing

Investigators wield impact as expert constituent voices

A couple of years ago I blogged about how fraud investigators can be key to enacting strong fraud laws.The state legislative season is heating up, so let’s revisit. We need to think of how to mobilize for action.

Lobbying legislators can be top-down and bottom-up.

Top-down involves national groups like the Coalition or insurers raising the issues with legislators. Often we testify before committees or the full chamber. That carries weight. We discuss the big picture, and how a state bill is good (or bad) for combating fraud from a larger viewpoint.

The bottom-up approach is the grassroots level. Investigators and other frontliners can take a lead role.

Investigators can wield great influence. State lawmakers listen to constituents. Local people put a local face on fraud bills. Investigators also are respected crime-fighting experts. That voice speaks convincingly to lawmakers. They may know little about a fraud bill — or the crime it combats.

A tag team is the best formula for rallying support for fraud laws: Local investigators work with national groups like the Coalition. We all bring vital strengths to the table.

State legislators usually don’t receive letters or messages about fraud issues. So when an investigator writes a letter, that could be the first time a legislator hears about the fraud bill, and why it’s good for the state.

This leads to my Rule of Five. One constituent letter raises few eyebrows in a legislator’s office. Five letters, and the legislator thinks about the issue. And 25 letters signals a groundswell of support. That can convince a legislator to support a fraud bill.

Enacting strong fraud laws has four positive goals. 1) Create an infrastructure for insurers to investigate and report scams; 2) Give fraud fighters laws and regs that are pillars for chasing down swindlers; 3) Oppose weak bills that undermine the fraud fight; and 4) Educate lawmakers about the benefits of strong fraud laws.

Together, our influence can place more fraud laws onto the books. We will educate lawmakers about how strong fraud laws benefit consumers throughout a state.

So let’s add a fifth goal for fraud laws: Empower consumers and insurers to better fight back against insurance fraud.

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

Fraud of the Month: Innocent patients die from Medicare, Medicaid looting

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by James Quiggle

Rafael Chikvashvili holds a PhD in math. He thought he was smart enough to steal $7.5 million from Medicare and Medicaid. Yet the numbers whiz sorely miscalculated. His con killed two patients, sending him to federal prison possibly for life.

The Baltimore-area brainiac ran an imaging firm called Alpha Diagnostics. He did X-rays, ultrasounds, heart exams and other medical tests. Most of his patients were seniors in nursing homes. He brought portable equipment and did the tests at the homes as a convenience to residents.

Doctors are required to interpret the tests. Correct diagnoses can save lives. Especially for frail seniors, who have less margin of medical error.

Yet Chikvashvili had untrained staff make the diagnoses and write up bogus medical reports. He then billed Medicare steep fees as if doctors had done the work. Chikvashvili even forged doctor signatures to the reports.

His death-dealing scam opened wider the door on rampant bilking of Medicare, the federal insurer for seniors. Medicaid, the state-federal insurer for the poor, bolted to the forefront with the horrifying abuse of a homebound cerebral palsy patient. Makayla Norman died at the hands of caergiver Mollie Parsons. The registered nurse rifled Medicaid while Makayla starved.

Medicare and Medicaid cons steal tens of billions of taxpayer dollars a year — arguably the largest form of insurance fraud in the U.S. Innocent patients also pay a frightening price for the so-called “victimless” crime.

Staff missed heart problems

Chikvashvili’s inept employees missed congestive heart failure that showed up on a woman’s X-ray. A qualified radiologist doctor should’ve reviewed the test results. The patient would’ve been transferred to an acute-care facility for treatment. Instead she stayed in a rehab nursing home, with a lower standard of care for her condition. She died four days after the mis-read chest X-ray.

An unqualified Chikvashvili staffer never saw another surgery patient’s mild congestive heart failure on a pre-op chest X-ray. She was cleared for surgery. She bled profusely during and after the operation. The patient died six days later.

An X-ray technician was vacationing in Jamaica. Chikvashvili ordered him to view other patients’ medical images using his personal laptop in his hotel room, then forge test reports as if he was a doctor. Alpha Diagnostics used the reports to make false Medicare claims.

Teen starved in bed

Then there’s the tragic death of Makayla Norman in a separate Medicaid scheme. The 14-year-old had cerebral palsy. Bedridden, the 14-year-old was confined to her home in Dayton, Ohio. Makayla couldn’t speak or move. She needed constant nursing care, including bathing and eating.

Her family was low income, so Medicaid paid home nurse Mollie Parsons to care for her six days a week, eight hours a day. Yet Parsons only showed up three or four times per month. Sometimes she didn’t even go inside. Instead she honked the horn so Makayla’s mother would come out and join her in shopping trips.

Parsons let the helpless teen die a horrifying death. All the while, she milked Medicaid with false medical reports. Makayla was healthy, Parsons lied. She was on duty, caring for Makayla and making her as comfortable as possible.

“Makayla “was a skeleton with skin draped over it. It was horrific,” a homicide detective said at Parsons’ trial on state healthcare fraud and other charges.Parsons let Makayla starve for a year, and ignored her medical care. Makayla’s body shrank to just 28 lbs. She was covered in filth and open bed sores. Her diaper hadn’t been changed. Her colon was so full with fecal matter that she had a noticeable bulge. Her hair and eyebrow were infested with lice.

Yet Makayla was in good health and and well-fed when Parsons left at 10 p.m., the nurse’s daily records said the day Makayla died.

Her mother called 911 just two minutes later. Makayla was having a hard time breathing. She was rushed to the hospital. It was too late, and she quickly died.

Makayla “was a skeleton with skin draped over it. It was horrific,” a homicide detective said at Parsons’ trial on state healthcare fraud and other charges. Parsons received 10 years in Ohio state prison, and will serve up to five more years in federal prison afterward.

“She was the worst malnourished child I think we’ve ever seen,” said Ken Betz, head of the coroner’s office.