Saturday, January 17, 2015

mHealth or Global Economy, Boom or Bust?

$10 billion was invested by Venture Capital companies in a single quarter in 2014 including investments in mHealth and Digital Health applications. At one level this may seem to be "irrational exuberance" as dramatically demonstrated in the internet bubble 15 years ago. The internet bubble effected the Global Economy and considering the size of the $3 trillion US Healthcare Market, mHealth may be an interesting indicator for a digital economy as a whole.

Valuations in digital / social media entities are at all time highs. Uber and Alibaba are easy examples. Xiaomi the Apple "knock off artist" just became the most valuable start-up at $45 billion. Considering China is Xiaomi's primary market, this valuation is astounding. I thought China was going through recession (based upon media reports) compared to its relative meteoric growth over the past 2 decades.

Rock Health's Managing Director, Malay Gandhi, makes a thoughtful case against any potential "bubble" in the digital health space in a report by stating, "it’s an inherent dissatisfaction in healthcare driving digital health’s growth; 258 digital health companies each raised more than $2 million in 2014. According to Rock Health’s report, the top six categories for digital health funding last year (accounting for 44 percent of all digital health funding in 2014) were: Analytics and Big Data ($393M), Healthcare Consumer Engagement ($323M), Digital Medical Devices ($312M), Telemedicine ($285M), Personalized Medicine ($268M), Population Health Management ($225M)."

Rock Health also points out that during the internet or dot-com bubble that over $30 billion was raised in a single quarter in internet company investments. This number is even more significant considering the realtive size of the US economy in 1999-2000 versus 2014. Malay Gandhi's analysis seems solid as well by comparing the tech heavy NASDAQ versus the Dow Jones in 1999- 2000 versus today. The stock index charts also support Gandhi's statements.

In 1987 the stock market crashed. In 1998 the global economy and the stock market crashed. In 2000 the tech heavy NASDAQ crashed. In 2008 the global economy and the US stock marked crashed. Comparison of the internet bubble of 2000 make today's NASDAQ and mHealth valuations appear conservative, especially considering the diversification of investments in today's market.

As a Vice President at Medical Manager Corporation (known today as WebMD), I remember thinking in March 2000, that maybe people will need to sell some stock to pay for some gains in the NASDAQ.

U.S. venture capitalists invested $48.39 billion last year, the biggest total since 2000, according to new data from the National Venture Capital Association, PwC, and Thomson Reuters.

“Internet models today are fundamentally more sound than Internet models of 2000,” said Deven Parekh of Insight Venture Partners, a firm which has backed Chinese online giant Alibaba.com and message service Twitter.

The $48.39 billion, spread among 4,356 deals, compares to $29.96 billion in 2013, and $105.01 billion in 2000, the largest level since the association began keeping records.

Software deals accounted for 41 percent of all cash, the highest percentage since the report’s inception.

The troubling scenario found in the stock index charts demonstrate a 1 year gain in GDP (2014 - 2015) of nearly $1.5 trillion in a single year. This is a significant increase in GDP during a time frame when global oil prices have been cut in half and copper prices are at 2009 levels. Like oil, copper is a significant indicator for industrial and construction activities,

There is a real pent up demand for restructuring in the US Healthcare System. A significant amount of this change will occur as a result of innovation. New technology adoption and addressing healthcare (Medicare and Medicaid) fraud and abuse will be highlighted in 2015. The future of digital health technologies look bright against potential global economic headwinds. Unlike 2000, the "economic eggs" are diversified among multiple baskets.

FBI investigating $110 million Medicaid Fraud Contract under Rick Perry Administration

The FBI is investigating a $110 million Medicaid Fraud Detection contract awarded to 21CT of Austin, TX. This is a case of the fox watching the hen house.

In this case a political appointee, the inspector general of the Texas Health and Human Services Commission, awarded a $110 million dollar no bid contract to a firm committed to detect fraud in medicaid services.

Gregg Cox, director of the district attorney's Public Integrity Unit, said he expects to open a criminal inquiry following two formal complaints into the now-canceled Medicaid fraud detection contracts given to Austin technology firm 21CT by Jack Stick, who last week resigned as general counsel at the state Health and Human Services Commission amid allegations of favoritism.

http://www.texastribune.org/2014/12/18/perry-calls-probe-21ct-hhsc-contracts/

http://www.statesman.com/news/news/state-regional-govt-politics/sources-fbi-is-investigating-110m-21ct-medicaid-fr/njnxd/

School Lunch includes Breakfast and Dinner

School lunch includes breakfast and dinner. Over 1 million children are receiving breakfast lunch and dinner at school. Los Angeles is doubling the number of dinners served.

The nation's second largest school district is doubling the number of students served dinner, with an eye toward eventually offering it at every school. It's a growing trend: Nationwide, the number of students served dinner or an after-school snack soared to nearly 1 million last year.

"When kids are hungry, they don't pay attention," said Bennett Kayser, a member of the Los Angeles Unified School District board, which was announcing the expansion Thursday. "This is something that should have started years ago."

Thirteen states and the District of Columbia began offering students dinner as part of a pilot program expanded to all states after the 2010 passage of the Healthy, Hunger-Free Kids Act. Schools where at least half the students are low-income and qualify for free or reduced-price lunch are reimbursed for each supper by the U.S. Department of Agriculture, at a rate often significantly higher than the cost of the meal.

Dentist paid $3.35 million in restitution but no jail time for Medicaid Fraud in Washington State

Sea Mar Health dentist paid $3.35 million in restitution but no jail time for Medicaid Fraud in Washington State.

OLYMPIA — Attorney General Bob Ferguson today announced that his office is recovering $3.35 million from Sea Mar Community Health Centers, stemming from allegations Sea Mar improperly billed Medicaid for thousands of dental appointments.
After a two-and-a-half-year investigation, the false claims unit of the Attorney General’s Medicaid Fraud Control Unit raised concerns that Sea Mar had overbilled Medicaid more than $3 million for dental services between 2010 and 2014.
The Attorney General’s Office alleged that fluoride treatments, which could have been performed by dental assistants as part of a patient’s regular six-month checkups, were instead billed as stand-alone appointments with a dentist or hygienist.
Fluoride treatments should be billed on a fee-for-service basis, usually between $13.25 (for 6-to-19-year-olds) and $23.41 (for younger children). Bills from Sea Mar instead were sent to Medicaid as “encounters,” indicating patients were seen by a dentist or hygienist, with a typical fee of $180. Medicaid billing rules dictate that in order to bill for an encounter fee, the dental service provided must require a dentist or dental hygienist to warrant the higher cost.
The false claims unit alleged that Sea Mar’s billing for these appointments also exceeded the number of dental exams allowed per patient under Medicaid, without any documentation of the findings of such exams or that the exams were actually performed.
“Without exception, providers who participate in our state’s Medicaid program must accurately bill for and document services provided,” Attorney General Bob Ferguson said. “I’m pleased my office was able to recover the excess taxpayer funds that went out the door so this money can go back into health care for those in need.”
The agreement also resolves a pending case filed by Sea Mar in federal district court. Sea Mar cooperated fully in the investigation.

Over $135 Million in Healthcare Fraud for The Week Ending January 16, 2015

Guilty plea for $32 million Medicare fraud

Felix Gonzalez, the owner of Miami-based home health care company AA Advanced Care Inc., pled guilty to leading a Medicare fraud scheme that netted $22 million of the $32 million in false claims that were submitted. The company provides home health and therapy services to Medicare beneficiaries, but was allegedly billing the Medicare program for expensive physical therapy and home healthcare service that were either not medically needed or not provided at all.

Gonzalez also admitted to negotiating and paying kickbacks and bribes to patient recruiters in exchange for patient referrals, as well as prescriptions, plans of care (POCs) and certifications for medically unnecessary services that could be billed.

Podiatrist plead guilty to $999,170 fraud

Dr. Lawrence Iken plead guilty to one count of healthcare fraud for submitting false claims for services that were submitted over an eight year period. Through his own company and acting as an independent contractor, Iken overbilled Medicare, Medicaid and private insurance companies for services that were never rendered. This includes billing for draining abscesses and hematomes when he only clipped patients’ toenails.

Dr. Iken agreed that over the time frame, he overbilled $999,170. He faces a maximum of 10 years in prison, personal fines up to $250,000 and a company fine of up to $500,000.

Orchestrators of $97 million Medicare scheme sentenced

The two owners of a Houston-area mental health clinic were sentenced to 148 months and 120 months respectively for orchestrating a $97 million Medicare fraud scheme. Mansour Sanjar and Cyrus Sajadi were found guilty of using their community mental health clinic from 2006 through 2011 to provide partial hospitalization program (PHP) services, which include outpatient treatment for severe mental illness, and billing for them, even if the beneficiaries did not qualify for the services. They also billed for services when residents were watching movies, coloring and playing games, which are not billable activities.

It was also discovered that the pair paid kickbacks to group home operators and patient recruiters for delivering ineligible patients.

“Doctors are not only bound by oath to serve the health of their patients, they are bound by duty to serve as gatekeepers for Medicare spending,” said Assistant Attorney General Caldwell. “In this case, without the criminal participation of Drs. Sanjar and Sajadi, this fraud simply could not have happened.”

Clinic owner sentenced to 30 months

Ronnie Lorenzo Robinson, the former owner of Peaceful Alternative Resources, was sentenced to 30 months in prison for his role in a $3.4 million Medicaid fraud scheme. The company provided mental health and mentoring services from two offices in North Carolina. The company submitted fraudulent reimbursement claims for fake mental health services which were either provided by unlicensed, non-Medicaid approved individuals, if they were provided at all.

Michigan physician gets 15 months for $2.1 million in fraud

Dr. Paula Williamson has been sentenced to prison for 15 months for her role in a $2.1 million Medicare fraud scheme. Between August 2009 and October 2012, Williamson and others committed healthcare fraud by referring Medicare beneficiaries for home health services that were medically unnecessary or never provided. Williamson also falsified documents to support the fake claims.

Settlement reached in $1 million fraud case

Nason Medical and two of its doctors have reached a $1,021,778.26 settlement. It was alleged that the provider submitted claims to Medicare that should have been provided by physicians, but were actually provided by physician assistants, some tests were not medically indicated and some radiological services were handled by technicians that were not licensed.

“Being a health care provider in Federal healthcare programs such as Medicare and Medicaid is a privilege, not a right. When health care providers order medically unnecessary procedures such as CT scans and submit other improper claims just to boost profits, they threaten both the health of their patients and the financial integrity of the Medicare and Medicaid programs,” said Derrick Jackson, Special Agent in Charge at the U.S. Department of Health and Human Services, Office of Inspector General (OIG).

http://revcycleintelligence.com/2015/01/16/the-week-that-was-in-healthcare-fraud-and-legality-3/

Financial AND Medical Identity Protection

http://insurancenewsnet.com/oarticle/2015/01/14/id-experts-launches-fraudstop-midas-edition-to-protect-victims-medical-identiti-a-584654.html#.VLo3CEfF91E

Healthcare data breaches have now affected almost 40 million individuals, according to statistics collected by the Department of Health and Human Services. The breaches have ranged from improperly disposed paperwork to sophisticated hackers stealing whole medical records and offering them for sale on the "dark" Internet.

"Offering credit monitoring to victims of a Protected Health Information data breach is ineffective and disingenuous, as it only monitors financial credit, and therefore can't detect further abuse of a victim's medical identity," said Meredith Phillips, chief privacy & information security officer at Henry Ford Health System.

Google wants to replace your Brain

Google's investment in Deep Learning makes business sense, but will it make people stupid?

Google is a

n artificial intelligence company. It uses its AI not just in search — though its search engine is positively drenched with artificial intelligence techniques — but in its advertising systems, its self-driving cars, and its plans to put nanoparticles in the human bloodstream for early disease detection. As Larry Page told me in 2002:

We don’t always produce what people want. That’s what we work on really hard. It’s really difficult. To do that you have to be smart, you have to understand everything in the world, you have to understand the query. What we’re trying to do is artificial intelligence…the ultimate search engine would be smart. And so we work to get closer and closer to that.

https://medium.com/backchannel/google-search-will-be-your-next-brain-5207c26e4523

Thursday, January 15, 2015

Trial of former Steelers team doctor rescheduled

A federal judge Wednesday reschedule the trial of a former Steelers team doctor to May 18 because of scheduling conflicts.

Richard Rydze, 64, of the Strip District was scheduled to stand trial Tuesday on 185 counts of painkiller and steroid trafficking and health care fraud.

Former Steelers Doctor in Fraud Case

Wearable technology will drive down healthcare costs

Health is on your wrist

America is dangerously fat. The nation’s obese population puts itself at greater risk of coronary heart disease, diabetes, stroke and cancer, while contributing $190 billion in annual health-care costs to an increasingly unsustainable system. Starbucks buys more than 270 million pounds of coffee each year, yet still manages to spend more on health insurance — about $300 million annually. America’s health-care burden drives up prices — General Motors adds $1,400 onto the cost of each vehicle sold to cover its own health-care costs — and puts the nation at a competitive disadvantage, compromising the opportunities of future generations.

Today’s wearable technology won’t solve America’s health problems, but a single irresistible device could be enough to heighten health awareness and transform America’s image and culture, just as the iPhone kick-started a worldwide technology obsession less than a decade ago.

http://www.govtech.com/health/Could-Better-Health-Be-all-in-the-Wrist.html

Wolf of Wall Street nabbed after FBI raid

http://www.miamiherald.com/news/article6499032.html

The real "Wolf of Wall Street" nabbed in #FBI raid on Medical Insurance Fraud

MIAMI

FBI agents and other investigators spent hours Wednesday apparently collecting evidence at a South Florida medical supply firm with links to "The Wolf of Wall Street" film amid accusations of Medicare fraud.

FBI spokesman Jim Marshall confirmed that the bureau was "conducting law enforcement activity" at the offices of Med-Care Diabetic and Medical Supply Inc. in Boca Raton. News media photos and video showed agents from the FBI and other agencies carting out boxes of files and other materials from the office.

Marshall would not discuss the nature of the case, but Med-Care is accused in a pending false-claims lawsuit of defrauding the federal Medicare program. The company has denied the allegations.

Read more here: http://www.miamiherald.com/news/article6499032.html#storylink=cpy

How to make $$$ and potentially go to JAIL via Medicare Fraud (Association of Certified Fraud Examiners)

10 popular health care provider fraud schemes

'DO NO HARM' ISN'T THEIR MOTTO

http://www.acfe.com/article.aspx?id=4294976280

January/February 2013

Charles Piper, CFE, CRT

Average 4 out of 5

$8.2 billion in Medicare and Medicaid money just rolled away on Wheelchairs

The wheelchair scam was designed to exploit blind spots in Medicare, which often pays insurance claims without checking them first. Criminals disguised themselves as medical-supply companies. They ginned up bogus bills, saying they’d provided expensive wheelchairs to Medicare patients — who, in reality, didn’t need wheelchairs at all. Then the scammers asked Medicare to pay them back, so they could pocket the huge markup that the government paid on each chair.

A lot of the time, Medicare was fooled. The government paid.

Since 1999, Medicare has spent $8.2 billion to procure power wheelchairs and “scooters” for 2.7 million people. Today, the government cannot even guess at how much of that money was paid out to scammers.

Wheels keep rolling in the dough

Obama: Medical Fraud is Top Priority in 2015

Obama "Medical fraud a Top Priority in 2015"

Courts in 2015 likely will continue to handle many healthcare fraud cases, particularly related to the anti-kickback law and the Stark law, which governs physician referrals and financial relationships, said Louis Saccoccio, CEO of the National Health Care Anti-Fraud Association. HHS' Office of Inspector General listed fighting fraud in Medicaid and Medicare among its top management and performance challenges for 2014.

Saccoccio predicted that fraud allegations involving pharmacies might gain a higher profile in 2015.

Big Data Analysis and novel fraud detection systems will make a significant impact in 2015.

http://www.modernhealthcare.com/article/20150110/MAGAZINE/301109989

Big Data catches Medicare Fraud in Real time

US authorities have saved billions of dollars by mining big data to identify and prosecute healthcare fraud, learning from the playbook corporations are using to disrupt their industries and expand their businesses.

DOJ uses Big Data to crack down on Medicare Fraud.

The US Department of Justice, Federal Bureau of Investigation and Department of Health and Human Services’ office of inspector general have been scouring billing records to identify frauds that are estimated to bleed Medicare, the taxpayer-funded ...

DoJ uses big data to crack Medicare fraud schemes - FT.com ft.com

New data analysis techniques from sophisticated algorithms are catching physicians committing fraud in "real time"

Wednesday, January 14, 2015

Personal Care Assistants are the Fastest Growing Occupation in the Country

Federal and State Regulations governing Medicare and Medicaid have created a unique class of worker in the United States Healthcare System. Personal Care Assistants (PCAs) will comprise over 1.2 million workers by 2018 and currently provide over 1.2 billion hours of care to elderly, disabled, and chronically ill patients. By 2020 PCAs will be providing more hours of care to a select group of patients with Disabilities, Diabetes, COPD, Alzheimer’s, Parkinson’s, and conditions associated with old age, then ALL of the physicians in the US providing care to the ENTIRE US patient population.

A majority of PCAs work as ”independent providers” employed by the patient and reimbursed under a Medicaid consumer directed program. PCAs may also be affiliated with a Medicare / Medicaid Intermediary (Home Health Agency).

It is estimated that PCAs account for over $25 billion in direct payments from Medicare and Medicaid. Furthermore, by providing over 25 million hours of care per week, PCAs influence over $100 billion annually in healthcare services (pharmaceutical, DME, etc…), shopping / dietary decisions, personal care, and financial decisions for the patients under their care. To date, the influence of PCAs on patient decisions in the healthcare provider hierarchy has been overlooked and underestimated.

Government regulations, an aging population, and increasing incidence of chronic disease are driving the growth of the PCA workforce at an unprecedented rate. As the number of hours of care provided to patients by PCAs is increasing, so to, is the incidence of fraud. The FBI, State Agencies, and healthcare organizations are attempting to address fraudulent Medicare and Medicaid billing on behalf of PCA services. A June 5, 2014 indictment in Illinois netted over 43 Medicare and Medicaid beneficiaries as well as Personal Care Assistants that were billing for services that never occurred.

According to an Office of Inspector General report released in December 2012, Medicaid costs for personal care services in 2011 totaled $12.7 billion, a 35 percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018. U.S Department of Health and Human Services, Office of Inspector General: Personal Care Services, Trends, Vulnerabilities, and Recommendations for Improvement, OIG-12-12-01 (November 2012). Home personal care is one of the fastest growing job categories in the country. However, the OIG’s report points to numerous problems in Medicaid personal care services that leave it vulnerable to improper payments, abuse, and fraud, including lack of training standards, uneven oversight of services provided, and failure to implement prepayment controls to prevent improper or fraudulent payments.

Personal Care Assistants should receive better access to education and increased wages commensurate with experience to elevate outcomes in our healthcare system Fraud detection is a critical component.

The “personal choice option” also known as “consumer directed care” in Medicare and Medicaid regulations allows PCAs to be chosen by patients. Fraud is a significant concern in care provided by PCAs in consumer directed care. In fraud cases, a patient will select an in-direct family member or a friend and agree to split some portion of the reimbursement. The fraudulent “PCA” does not even have to show up at the patient’s residence and time sheets are forged. The Medicare and Medicaid reimbursement rates for PCAs are approximately $20 per hour.

Fraud remains a looming concern in home care; the US Government Accountability Office reported “estimated improper payments for Medicare of almost $48 billion for fiscal year 2010,” including expenditures for home oxygen and other home health claims. To qualify for coverage from payers or to generate incentives within insurance for individuals, home care technologies may also offer new avenues to address home care fraud, in addition to improving patients’ health and quality of life and saving money.

Franchised Home Health Care Agencies are fast pace. The leading franchises in terms of number of locations or “units” are Home Instead, Comfort Keepers, Home Helpers, and Visiting Angels. These four brands account for about 2,400 locations. The largest franchises in terms of corporate revenue are Home Instead, Interim HealthCare, Visiting Angels and Comfort Keepers. Some of these organizations have expanded their networks internationally. Home Instead is considered to be not only the leading senior care franchise but also the largest franchise system period in the U.S. And in 2010, Comfort Keepers made it onto the Inc. 500 list of the top 500 fastest‐growing companies in the U.S. with a three‐year sales growth of 32 percent.[1]

[1] Paraprofessional Healthcare Institute, Caring in America, December 2011.

Doctors caught stealing $97 million from Medicare

http://www.enewspf.com/latest-news/law-and-order/federal-and-international/58198-physician-owners-of-mental-health-clinic-sentenced-for-97-million-medicare-fraud-scheme.html

Medicare and Medicaid Fraud cost over $68 billion.

Court Orders FitBit to prevent Medical Fraud?

http://www.techworld.com/wearables/could-data-from-wearable-devices-land-you-in-jail-3590163/

Wearable sensors, monitors, and trackers can be used in court to track personal injury fraud claims.