A Record Breaking Insurance Fraud Uncovered

Dr. Jose Katz, a prominent cardiologist from Closter pulled off what authorities say was one of the largest healthcare fraud schemes in history.  Over $19 million was pilfered by Dr. Katz, which is what authorities cited as being the largest such fraud ever committed in New Jersey, New York, or Connecticut.  His two companies, Cardo-Med Services LLC and Comprehensive Healthcare & Medical Services,  treated patients & Dr. Katz intentionally subjected them to various unnecessary tests and procedures, which he billed to Medicare, Medicaid, Aetna, and other agencies for reimbursement, according to U.S. Attorney Paul Fishman.

Clearly, Dr. Katz found a loophole in the system.  My question is how in the world does this go on unnoticed?  In an age where just about everything is electronic and we have so many systems interacting with each other, it would seem like a flag would  have gone off.  Another question this poses is how can we assure that there are not other physicians out there that doing the same thing?  In most cases, doctors will immediately be taken at face value due to their trade; so how can we raise the bar to the “eye ball” test?  Legislation is not likely to make a difference in these types of situations.  No, this is an issue that calls for more checks and balances by insurance agencies and hospital administrators. Let’s hope that the authorities are hot on the trail of any other physicians guilty of such heinous acts.  As we say in our “text-speak”, SMH 

http://www.nj.com/bergen/index.ssf/2013/11/closter_cardiologist_sentenced_to_78_months_for_record_19m_healthcare_scam.html

Healthcare.gov - All the Pieces Are Not Completed Yet

Henry Chao, Deputy Chief Information Officer for CMS, testified yesterday that the CMS team is still building some of the website’s back-end systems.  These systems don’t affect what consumers see when they shop for plans but are necessary to carry out the financial and payment processes involving insurers.  My question is why wouldn’t we have a complete system in place prior to launching?  I can only imagine the kind of issues that will arise from assembly the back-end system with the user-facing system that is already plagued by bugs.  I just cannot foresee how this will be a good outcome.  If anything, this is will certainly delay the premier of a fully operational government exchange.  

Speaking of those bugs, CMS spokeswoman Julie Bataille said the CMS has now completed two-thirds of the “high-priority bugs” that the administration's tech team has identified that pertain directly to the so-called 834 notices that are necessary to transmit enrollment information to insurers.  Well, I guess one-third is better than nothing.  

It seems as if we are not gonna meet that January 1^st deadline for a smooth running machine.  But, as I said in my research paper, I still have faith in the government to fix this issue. 

http://www.modernhealthcare.com/article/20131119/NEWS/311199958/cms-calls-healthcare-gov-fixes-attainable-though-some-parts-arent

Healthcare.gov - I Told You So??!!

I have a report for my PADM 5322 class about the less than ceremonious launch of healthcare.gov and a came across this story/video.  In it, Marc Hill of the Huffington Post states that new since last spring that there was an issue with healthcare.gov roll-out.  He said that the consultants on the project, McKinsey & Co, stated that there was not enough time to test out the site prior to the launch in a fourteen page PowerPoint.  .  He also says that Obama’s officials were warned against taking risks to meet deadlines.  It also found that the project lacked comprehensive testing, noted many functions were dependent on contractors and warned against taking risks to meet deadlines.  

I don’t know about you, but if I have a consulting firm advising against a move I think I would listen.  After all, what is the point of having a consulting team assigned to a task if you don’t take heed to the findings and recommendations?  Now, of course, McKinsey & Co had no comment, saying that its work for clients is confidential.  Sounds like a veiled “yes but I cannot say that” answer to me.  Like all good leaders, the government needs to realize that God gave us two ears so that we can listen effectively.  

http://www.huffingtonpost.com/2013/11/19/obamacare-report_n_4299919.html

Nurses VS Doctors - An Age Old Battle

We recently covered in PADM 5322 incidents relating to the disparity between nurses and doctors.  It made me think back to some of the stories my mother used to tell my father (and me when I become of age to discuss “grown folks” issues).

My mother used to be an RN for Phoebe Putney hospital back in the 80s.  I remember her talking to my father about her day was.  She would always speak highly of her patients and most of her co-workers, but she would rarely say anything about the doctors.  Surely she had a good relationship with them.  This was evidenced by the amount of doctors that assisted her anytime one of us had a fundraiser.  They would always give the most.  Surely they didn’t mistreat her.  She was well trained and graduated top of the class at the illustrious Albany State University.  She also quickly rose through the ranks and eventually became the director over southwest GA in her field.  No, she told me later in life that she realized there was a “line drawn” between nurses and doctors.  She also witnessed how doctors treated other nurses disrespectfully and even condensending.  Now, even though she never had this happen to her, she had enough insight on how to handle herself in interactions with the doc tors.  This also was the reason why she left Phoebe Putney after over 10 years of service.  

In looking for material, I found a blog written by one of my colleagues.  She was dead on with her recommendations.  Clear communication, accountability, and an examination of policies would certainly help even the playing field.  I’m not saying that doctors and nurses are both one in the same…but I am saying that they are both human beings in the business of saving lives.  We certainly need these two parties to get along famously so that we can have continued efficiency and quality in healthcare.  

http://melaniechambers21.blogspot.com/2012/03/pln-7-physician-nurse-conflict.html 

Toxic Comination - Bad Coding & Bureaucracy

Upon performing my research for a paper in my PADM 5322 class, I stumbled across an article about how a combination of bad coding and bureaucracy is the problem with healthcar.gov.  There was a quote from a programmer that stated, off the record of course, that the requirements were constantly changing.  Seeing how the programmers were using the waterfall method, I can see how that creates issues.  In a nutshell, the waterfall method begins with the requirement process, and then move to coding, then move to testing, and then releases an entire system.  If there was interference with this method (i.e. requirement changes), this would point to political pressure.  In addition to tampering with the requirements, this article pointed to the timeframe the developers were held to even though they insisted that the product was not ready.  This, again, points to political pressure.  It would be beneficial, at least in the aforementioned scenarios, for the government to allow the programmers to do their job without constraints and with as static requirements as possible.  Indeed, bureaucracy and bad coding make a devastating tandem. 

http://www.healthcareitnews.com/news/bad-code-bureaucracy-prove-toxic-combo-healthcaregov?single-page=true