MedWorm Tags: claims

Study Shows Value of NLP in Pinpointing Quality Defects

EMR and HIPAA — Thu, 25 Aug 2011 21:47:57 +0100

For years, we’ve heard about how much clinical information is locked away in payer databases. Payers have offered to provide clinical summaries, electronic and otherwise, The problem is, it’s potentially inaccurate clinical information because it’s all based on billing claims. (Don’t believe me? Just ask “E-Patient” Dave de Bronkart.) It is for this reason that I don’t much trust “quality” ratings based on claims data. Just how much of a difference there was between claims data and true clinical data hasn’t been so clear, though. Until today. A paper just published online in the Journal of the American Medical Association found that searching EMRs with natural-language processing identified up to 12 times the number of pneumonia c...

Whistleblower Lawsuit Against Amgen Is Reinstated

Pharmalot — Mon, 25 Jul 2011 22:24:53 +0100

Last month, a federal court ruled that a drug or device maker remains liable under the False Claims Act even when a pharmacy or hospital was unaware that a kickback was made to a doctor to induce the sale of a product for which reimbursement was sought from Medicare and Medicaid. The decision was seen as a game changer, because dismissing whistleblower lawsuits would likely become more difficult. Until then, courts had ruled the False Claims Act could not have been violated if a pharmacy does not know that a prescription was only written because a drugmaker gave a kickback to a doctor. Whistleblowers have argued, however, that a violation occurs once reimbursement is sought from Medicaid or Medicare. But the US Court of Appeals for the First Circuit disagreed. Not surprisingly, the same co...

Novo Nordisk Pays $25M For Off-Label Marketing

Pharmalot — Fri, 10 Jun 2011 15:52:08 +0100

The Danish drugmaker has agreed to pay $25 million to settle a whistleblower lawsuit to settle charges of off-label marketing its NovoSeven treatment to stop bleeding. As part of the settlement, Novo Nordisk has entered into a five-year Corporate Integrity Agreement and will have to beef up its compliance procedures, according to a statement from the drugmaker. The lawsuit - which was filed jointly by a Oscar Montiel, a former Novo Nordisk medical liasion, and Ian Black, a former US Armed Forces physician in federal court in Maryland - alleges the medication was promoted improperly for treating unapproved uses such as blood trauma, intercranial hemorrhage and various surgeries, according to a source familiar with the case. The charges included improper payments made to Army personnel (here...

UCB Pays $34M To Resolve Off-Label Charges

Pharmalot — Thu, 09 Jun 2011 17:57:19 +0100

Yet another drugmaker has been tagged for illegal marketing. This time, the US subsidiary of Belgium’s UCB has agreed to pay more than $34 million to resolve civil and criminal charges surrounding off-label promotion of its Keppra epilepsy drug, the US Department of Justice disclosed. Under the terms of the plea agreement in the US Court for the District of Columbia, UCB pleaded guilty to a misdemeanor in connection with misbranding of Keppra, which was approved for treating seizures in adults and children. But Keppra is not approved for the treatment of migraine, headache, psychiatric conditions or pain conditions. And guess what UCB promoted Keppra for treating? That’s right. The feds alleged that UCB promoted off label by creating and distributing posters indicating the drug...

Homeopathy: Why is Fraud Legal?

Better Health — Thu, 21 Apr 2011 15:00:16 +0100

Imagine hearing a commercial on the radio: Send us money, and we won’t send you anything in return. No one would do that, right? How about this: Send us your money and we’ll send you an empty box. Better? Not much. Now how is that different from: Send us money and we’ll send you stuff we’ll call medicine that we claim will help you, but there’s no actual active ingredients in it at all. I don’t think there’s one bit of difference. Wouldn’t you agree that that commercial is fraud, pure and simple? The problem is that the general public doesn’t understand that the word “homeopathic” means “diluted beyond the point where it contains any active ingredients.” I’ve recently heard commercials for homeopathic vertigo treatments, eye drops for allergies, irritable bowel,...

Whistleblower Suits Do Not Violate 1st Amendment

Pharmalot — Tue, 29 Mar 2011 11:55:34 +0100

A provision of the False Claims Act that prevents whistleblower lawsuits from being unsealed does not violate the First Amendment and, therefore, the public’s right to access the documents, a federal appeals court has ruled. In a 2-to-1 vote, the US Court of Appeals for the 4th Circuit upheld an earlier decision that shot down the argument whistleblower lawsuits should be unsealed after a 60-day period because this would allow the public to learn as soon as possible about corporate wrongdoing. The rationale for requiring these lawsuits to remain sealed for at least 60 days is to allow the feds, who are permitted to seek extensions beyond that initial period, to investigate the allegations. During the seal period, the whistleblower is not supposed to discuss the suit or its contents. ...

Amgen Execs Take The 5th Over Alleged Kickbacks

Pharmalot — Thu, 03 Mar 2011 03:02:31 +0100

Five former Amgen execs have ‘taken the Fifth’ in depositions that were conducted as part of a False Claims Act lawsuit scheduled to go to trial in federal court in Boston later this year. And the former Amgen sales rep and product manager who brought the lawsuit is fighting to have the depositions filed in court and made public. At issue are allegations that Amgen provided free ‘overfills’ of its Aranesp anemia medication and encouraged doctors to bill Medicare and Medicaid for the extra amounts. The lawsuit, which was filed by Kassie Westmoreland, also charges the biotech offered kickbacks to doctors in the form of fictitious consulting arrangements and weekend getaways in order to steal market share from Johnson & Johnson, which sells the rival Procrit treat...

Don't let customized applications snarl cash flow during ICD-10 conversion

Healthcare IT News Blog — Tue, 01 Mar 2011 15:48:50 +0100

Most healthcare organizations have modified or customized their billing applications to meet their own unique needs in regard to payer mix, clinical programs, or provider-based billing arrangements. While these customizations are fine for their intended purposes, they nonetheless pose rather large obstacles to the ICD-10 code conversion process. read more (Source: Healthcare IT News Blog)

J&J Accused Of Fraud By Former Sales Manager

Pharmalot — Fri, 25 Feb 2011 13:13:03 +0100

A former Johnson & Johnson sales manager accused the health care giant of concocting various schemes to defraud federal and state Medicaid programs in a lawsuit that was filed in 2005, but only recently unsealed amid a transfer of the litigation from a federal court in Pennsylvania to another in Massachusetts. The lawsuit was filed by Scott Bartz, a New Jersey resident who worked as a sales compensation manager from 1999 until 2007, when he alleges he was terminated in retaliation for repeatedly complaining about illegal marketing practices. His lawsuit also names the Omnicare nursing home operator and McKesson, the pharmaceutical wholesaler. In his complaint, Bartz charged J&J manipulated sales data; reported false prices to various government health programs, and paid kickback...

Why The Ohio AG Wants A False Claims Statute

Pharmalot — Wed, 23 Feb 2011 16:28:43 +0100

Earlier this month, a Medicaid managed care provider in Ohio agreed to pay $26 million to settle a whistleblower lawsuit brought by former employees, who alleged that assessments of adults and children with special needs were never conducted, but data was submitted anyway to the state Medicaid program for reimbursement. What has this episode to do with drugmakers? Well, the state of Ohio collected $10 million of the total $26 million paid by CareSource, the managed care provider. And Ohio attorney general Mike DeWine then bemoaned publicly that the state would have received more money if there was a False Claims Act statute on its books (look here). In general, such a law would allow Ohio to collect a bigger payday each time it participates in a whistleblower settlement. And in an era of i...

Posting About Health Concerns on Facebook, Twitter

World of Psychology — Tue, 01 Feb 2011 18:10:47 +0100

If you’re thinking about posting your health or mental health concerns on Facebook or Twitter, you may want to think twice. According to an article published last week in The LA Times, health insurers will often turn to social networks to check out someone’s story — especially when that person is receiving medical leave or disability payments from an insurer. If you’re filing (or intending to file) a health insurance claim, be careful. This once-hypothetical scenario is now commonplace, as insurers look for ways to keep cutting costs and payments to what they perceive as people intending to commit fraud against them. In fact, insurance companies don’t just randomly check out a social networking website when a claim comes in — it is now standard practice,...

When A Surgeon’s Note Must Begin With “I Certify…”

Better Health — Fri, 28 Jan 2011 20:00:00 +0100

You know it’s bad when the attending surgeon has to write this at the beginning of his operative note: “I certify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services.” So there you have it. -WesMusings of a cardiologist and cardiac electrophysiologist. *This blog post was originally published at Dr. Wes* (Source: Better Health)

When A Surgeon’s Note Has To Begin With “I Certify…”

Better Health — Fri, 28 Jan 2011 20:00:00 +0100

The Feds Are Investigating How Many Fraud Cases?

Pharmalot — Fri, 28 Jan 2011 13:20:11 +0100

Earlier this week, the US Department of Health & Human Services trumpted its track record in recovering $4 billion from investigations of healthcare fraud, some of which was made possible thanks to qui tam, or whistleblower lawsuits alleging violations of the False Claims Act (you can read the report here). Many drugmakers were targets and paid big fines, (back story) and the implication offered was that more such settlements are in the offing. But how many investigations are actually under way? The answer came just a couple of days later courtesy of US Senator Chuck Grassley, who referenced some data the HHS provided him in a Jan. 24 letter that was written in response to a request he made last month for a breakdown of the fraud probes. And so we now learn that, as of Jan. 4, there w...

About Scar Prevention And Treatment

Better Health — Mon, 27 Dec 2010 15:00:30 +0100

I saw a Scarguard product on sale at a drugstore locally. The claims on the packaging were over the top as usual: 1. “Guards against new scars forming” – Difficult to prove. 2. “Flattens and shrinks old scars” – Not really. 3. “Scarguard is the #1 choice of plastic surgeons” – Really? Nobody asked me. Scar treatment is pretty simple. Avoid wounding if you can. If you have plastic surgery, seek a skilled surgeon who will spend the time to do the best. After surgery avoid sunlight and smoking, and consider scar massage as directed by your surgeon. This “Scarguard” product is not going to make a bad scar much better unless it is applied early, and even then the results are debatable. - John Di Saia, M.D. *This blog post was originally published at Trut...

What 20 Years Of Pharma Fraud Has Wrought

Pharmalot — Fri, 17 Dec 2010 14:44:48 +0100

Once upon a time, defense contractors were considered the biggest hucksters. You know, the US Defense Department would pay $10 for a pencil. Now, though, drugmakers have surpassed every other industry when it comes to defrauding the US government, according to a new analysis by Public Citizen, which calls for stiffer penalies and increased criminal prosecution of pharma execs. The findings: Of 165 settlements comprising $19.8 billion in penalties during the past 20 years, 73 percent of the settlements and 75 percent of the penalties - representing $14.8 billion - have occurred in just the past five years. And four drugmakers - GlaxoSmithKline, Pfizer, Eli Lilly, and Merck’s Schering-Plough -accounted for 53 percent, or $10.5 billion, of all financial penalties. The chart below shows ...

OIG Issues Roadmap on Avoiding Medicare and Medicaid Fraud and Abuse for New Physicians

Health Care Law Blog — Fri, 05 Nov 2010 15:31:01 +0100

The U.S. Department of Health and Human Services, Office of Inspector General (OIG) has issued a resource and educational guide for new physicians to help them better understand the key Federal fraud and abuse laws.As a health care attorney who often deals with physicians on fraud and abuse related matters, I applaud the OIG's effort to provide educational information to help raise the level of understanding on these issues and increase the transparency of these federal laws. This guide won't just be useful for "new" physician but for all physicians to gain a better understanding of the very complex legal/regulatory structure of fraud and abuse laws in the United States.The new OIG document is titled, "Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse." The physici...

And Here Is The SEC Whistleblower Program

Pharmalot — Thu, 04 Nov 2010 13:41:59 +0100

After months of reviews and meetings, the US Securities and Exchange Commission has proposed a whistleblower program that was mandated by Congress as part of the Dodd-Frank Wall Street Reform and Consumer Protection Act. And the agency describes its approach as “a simple, straightforward procedure for would-be whistleblowers” to provide information. To be considered for an award, the SEC says that a whistleblower must “voluntarily provide the agency with original info about a violation of federal securities laws that leads to the successful enforcement by the SEC of a federal court or administrative action in which the SEC obtains monetary sanctions totaling more than $1 million.” The issue is of concern to the pharmaceutical industry, given that many drugmakers hav...

10-Question Checklist to Assess Products Making Brain Fitness & Training Claims

SharpBrains — Fri, 29 Oct 2010 14:24:06 +0100

To help consumers and professionals navigate through the growing number of programs making “brain fitness” or “brain training” claims, we have published this SharpBrains Checklist: 10 Questions to Choose the Right Brain Fitness Program — and a brief explanation of why each question is important: * 1. Are there scientists, ideally neuropsychologists, and a scientific advisory board behind the program? Neuropsychologists specialize in measuring and understanding human cognition and brain structure and function. * 2. Are there published, peer-reviewed scientific papers in PubMed written by those scientists? How many? PubMed is a service of the U.S. National Library of Medicine that includes millions of citations science journals. If a scientist has not published a paper that appear...

Healthcare Fraud, Whistleblowers & US Treasury

Pharmalot — Mon, 25 Oct 2010 12:32:03 +0100

There have been numerous headlines lately about healthcare fraud and whistleblowers whose lawsuits eventually prompted huge settlements with the federal government. The latest tally, however, shows that the US Department of Justice recovered over $3.1 billion in fraudulent claims in the 2010 fiscal year that can be traced to lawsuits filed under the federal False Claims Act. Specifically, there were 145 FCA cases settled in the 2010 fiscal year and the 10 largest settlements involved health care fraud, with eight involving drugmakers, according to Taxpayers Against Fraud, a non-profit that supports whistleblower lawsuits. The 10 largest cases accounted for $2.7 billion recovered. Although fiscal year 2009 actually recovered a larger pot of money - $5.6 billion. It also worth that health ca...

Pharmalot… Pharmalittle… Good Morning

Pharmalot — Mon, 04 Oct 2010 11:49:48 +0100

Hello, everyone. Nice to see you again. We hope the weekend was refreshing and restful. Now, of course, the time has come to resume the routine as those meetings and deadlines await. So please join us as we reach for the mandatory cups of stimulation (yes, we are two-fisted drinkers here at the Pharmalot corporate campus) and scan the news of the world. Have a good day and stay in touch… Sanofi Begins Hostile Bid For Genzyme (Associated Press) Reata Pharmaceuticals Adds Jobs After Abbott Deal (Dallas Business Journal) J&J Warns Concerta Sales Reps About Layoffs (The Wall Street Journal) Will Lilly Bid For MannKind? (The Indianapolis Star) Sihuan Pharma Sets $700M IPO (Reuters) South Africa Researches Plant That Lifts Moods (Associated Press) Antipsychotics, Illegal Marketing And...

Feds Give Lipitor Whistleblower Lawsuit A Boost

Pharmalot — Mon, 27 Sep 2010 15:28:45 +0100

Earlier this year, a former Pfizer exec amended his whistleblower lawsuit accusing the drugmaker of illegally scheming to boost Lipitor sales by misrepresenting product labeling and federal cholesterol guidelines; using misleading educational programs for doctors, and unlawful sampling kickback schemes that resulted in off-label marketing that allegedly defrauded Medicaid and Medicare. Jesse Polansky, who was director of outcomes management from April 2001 until July 2003, claims “thousands of physicians have prescribed Lipitor to millions of patients for whom drug therapy is not recommended, and for whom the medication could be dangerous. Millions of those improper prescriptions were ultimately paid for by various government healthcare plans, the suit charges. And in a newly filed brie...

Peter Rost Loses Whistleblower Suit Against Pfizer

Pharmalot — Thu, 16 Sep 2010 15:22:11 +0100

After several years of legal sparring, a federal judge has dismissed the whistleblower lawsuit that Peter Rost filed against Pfizer. For those who do not recall, Rost is the controversial former Pfizer exec who allegated that Genotropin, a human growth hormone, was marketed for unapproved uses, such as combating aging in adults and treating short stature in children. The drug was initially marketed by Pharmacia, which is where Rost worked before the company was bought by Pfizer. The US Justice Department failed to join his lawsuit, but Rost last year succeeded in winning the right to proceed on a narrower basis by attempting to cite numerous instances in Indiana and Kentucky in which Genotropin marketing may have violated the federal False Claims Act. Specifically, he argued Pfizer engaged...

Coffee Grounds To Combat Cellulite?

Better Health — Sat, 11 Sep 2010 20:00:26 +0100

Last week a popular TV talk show featuring a bunch of doctors (I’m not naming names) discussed how coffee grounds can improve cellulite. They explained how rubbing coffee grounds into your skin imparts caffeine into the cellulite thereby improving the circulation and drawing the toxins out. This is a great tip, except that rubbing coffee grounds on your skin does not impart any caffeine into it, and there are no toxins in cellulite. Cellulite is a normal secondary sex characteristic of women. It is the result of thin connective tissue in women’s skin. Massaging the cellulite (with coffee, tea, grapes, cream cheese, or chocolate frosting) pushes the fat back into the skin, temporarly improving the appearance. There is no science behind using coffee to treat this normal condition. Scient...

Testosterone For Anti-Aging In Men: A Medical Fraud?

Better Health — Thu, 19 Aug 2010 12:00:29 +0100

On the car radio, I have several times happened upon “infomercial” programs touting the benefits of testosterone replacement therapy for men, broadcast by doctors who specialize in prescribing the drugs. They have lots of wonderful stories about men who feel younger, happier, and more vigorous because of their macho remedies. It’s a tribute to the power of the placebo. I have been reviewing John Brinkley’s goat gland scam for a presentation on medical frauds. In an era before the isolation of the hormone testosterone, Brinkley transplanted goat testes into human scrotums in an attempt to treat impotence and aging. We are more sophisticated today — but not much. Longevity clinics and individual practitioners are offering testosterone to men as a general pick-me-up and anti-agi...

19th Century “Cure” For Obesity

Better Health — Sun, 18 Jul 2010 12:00:00 +0100

I really want to know what the treatment is that this “regular practicing physician” sent to the patient to reduce the surplus flesh. “Eat as much and as often as you please” and “no bandaging nor tightlacing.” Bring it on! *This blog post was originally published at EverythingHealth* (Source: Better Health)

One Critic’s Take On The “Multigrain” Scam

Better Health — Sun, 18 Jul 2010 01:06:23 +0100

Freelance journalist and author Suzanne Schlosberg wrote because she was so upset over a New York Times story, “The Chip That Stacks Adds a Multigrain Twist,” that she wanted us to review it. I thought anyone who feels so strongly about something should review it herself. So she did. Here is Suzanne’s guest post: ************************** I was flabbergasted when I read this New York Times piece on Procter & Gamble’s new entry into the potato-chip market: multigrain Pringles. The story accepts at face value P&G’s misleading marketing pitch — that “multigrain” is equivalent to “healthy.” When I sent a link to my nutritionist friend Cynthia Sass., M.S., R.D., she replied: “Did you notice it says ‘advertisingR...

PTSD Benefits Now Easier to Get Through VA

World of Psychology — Sat, 10 Jul 2010 17:10:41 +0100

Good news for veterans — the U.S. Veterans Administration is easing rules in order to qualify for benefits related to post-traumatic stress disorder (PTSD). Under the new rules to be introduced as early as next week, soldiers will no longer have to show documentation that they directly experienced or were witness to a “traumatic event” — like a firefight, a bomb blast, or the death of a friend in combat. Getting supporting documentation has sometimes been a frustrating and challenging experience for soldiers. War zones aren’t always known for keeping the best paper records, and not every action or firefight is well-documented. According to The New York Times’ article, “Under the new rule, which applies to veterans of all wars, the department will ...

Grassley, Drugmakers And Whistleblower Protection

Pharmalot — Thu, 01 Jul 2010 14:34:30 +0100

Since the passage of the False Claims Act in 1986, the federal government has recovered about $22 billion through qui tam, or whistleblower lawsuits and a fair number of these have emanated from the pharmaceutical industry. An untold number of such lawsuits are always in the wings, as people who work with or for drugmakers attempt to expose alleged wrongdoing. There have been accusations that some whistleblowers are only in it for the money (see this), but life as a whistleblower has its challenges (see here). And so concerned that the pharmaceutical industry may not be doing enough to educate employees about whistleblowing protection, US Senator Chuck Grassley has written 16 big drugmakers to provide information about their programs. The letters went to Abbott Labs, Amgen, AstraZeneca, Br...

J&J Loses Bid To Dismiss Whistleblower Lawsuit

Pharmalot — Tue, 22 Jun 2010 12:02:45 +0100

The US Supreme Court rejected an appeal by Johnson & Johnson’s Ortho-McNeil unit, which sought to stop a whistleblower lawsuit brought by Mark Duxbury, a former sales rep, who claimed the drugmaker gave kickbacks to docs and hospitals to induce them to prescribe the Procrit anemia med. These alleged kickbacks included free samples; off-invoice discounts; rebates; consulting fees; educational grants; payments to participate in studies, and advisory board fees. He also charged Ortho-Biotech inflated Procrit’s average wholesale price; promoted higher dosing than what was approved by the FDA, which generated larger government reimbursements to health care providers; and ran “sham drug trials” to falsify Medicare reimbursement for off-label use (background here and here). The l...

Novartis Pays $72.5M Fine For Off-Label Marketing

Pharmalot — Wed, 05 May 2010 12:19:10 +0100

Two units of the big drugmaker - Novartis Vaccines & Diagnostics and Novartis Pharmaceuticals - agreed to pay the $72.5 million fine in order to resolve civil False Claims Act charges over the marketing of the TOBI cystic fibrosis medicine that took place between January 2001 and July 2006. The US Justice Department charged Novartis and Chiron, which Novartis purchased in 2006, caused false claims to be submitted to federal health care programs for off-label uses and for patients who shouldn’t have received the drug (here is the settlement). The federal government will get $43.5 million and various states will receive $29 million. Meanwhile, three former Chiron employees – Robert Lalley, Courtney Davis and William Manos – who filed whistleblower, or qui tam lawsuits, will re...

Qui Tam states in yellow

PharmaGossip — Wed, 05 May 2010 08:16:00 +0100

http://www.taf.org/statefca.htmGo to the link - the map there is interactive. (Source: PharmaGossip)

Will States Restrict Their Whistleblower Lawsuits?

Pharmalot — Tue, 04 May 2010 15:44:30 +0100

Three years ago, a federal law was enacted that provided incentives to states to pass their own versions of the False Claims Act, which allows people who are not affiliated with the government to file lawsuits against federal contractors claiming fraud against the government. There have been a spate of these whistleblower, or qui tam, lawsuits in the pharma world lately (see here, here and here). The Department of Health and Human Services and the Department of Justice were chartered with overseeing whether the states are meeting the qualifications that would allow them to receive a share of any proceeds recovered. And so last week, Senator Chuck Grassley, the ranking Republican on the Senate Finance Committee, who regularly probes drugmakers, wrote the agencies because only 14 states are...

J&J Pays $81M Over Off Label Marketing Charges

Pharmalot — Thu, 29 Apr 2010 18:12:55 +0100

The health care giant’s Ortho-McNeil Pharmaceutical and Ortho-McNeil-Janssen Pharmaceuticals subsidiaries are ponying up $81 million in order to resolve criminal and civil lawsuits charging the units with illegally promoting the Topamax epilepsy drug. This is one of three such agreements the Justice Department announced this week. Also today, Schwarz Pharma will pay $22 million for failing to tell the Centers for Medicare and Medicaid Services that two unapproved drugs didn’t qualify for coverage under federal health care programs. And earlier this week, AstraZeneca agreed to pay $520 million for off-label promotion of the Seroquel antipsychotic (see here). Unlike the J&J charges, these two oher cases didn’t involve criminal charges. One thing all three settlements h...

BBC “Brain Training” Experiment: the Good, the Bad, the Ugly

SharpBrains — Wed, 21 Apr 2010 05:50:29 +0100

You may already have read the hundreds of media articles today titled “brain training doesn’t work” and similar, based on the BBC “Brain Test Britain” experiment. Once more, claims seem to go beyond the science backing them up … except that in this case it is the researchers, not the developers, who are responsible. Let’s recap what we learned today. The Good Science The study showed that putting together a variety of brain games in one website and asking people who happen to show up to play around for a grand total of 3-4 hours over 6 weeks (10 minutes 3 times a week for 6 weeks) didn’t result in meaningful improvements in cognitive functioning. This is useful information for consumers to know, because in fact there are websites and compani...

The meaningless and misleading nature of food health claims

Dr John Biffa's Blog — Thu, 25 Feb 2010 17:37:19 +0100

On Tuesday I was giving a presentation, and part of my advice was for individuals to avoid eating much in the way of processed food, including those emblazoned with health-related claims. Terms such as ‘low fat’, ‘low cholesterol’, and ‘high in fibre’ are misleading, to begin with, because these qualities have dubious health benefits (if [...] (Source: Dr John Biffa's Blog)

Why Crash Rates Don’t Automatically Fall with Cellphone Bans

World of Psychology — Sat, 30 Jan 2010 19:06:56 +0100

Last week, the Highway Loss Data Institute released a report that examined whether collision claims had gone up, down, or stayed the same in states that have banned cellphone use while driving. Their findings should have surprised no one, but seemed to have surprised everyone — crash rates did not go down after a hand-held cellphone ban took effect. Why should this have been of little surprise? 1. A law doesn’t automatically change human behavior. Laws can be wonderful things, but they are only as effective as when people obey them. This is often done with a stick — enforcement — rather than a carrot (such as incentives for safe driving practices). The laws have, according to the New York Times reporting on this study, reduced the use of hand-held cellphones 41 to 7...

Part One: Stage One Meaningful Use Winners

Healthcare IT News Blog — Mon, 04 Jan 2010 14:43:51 +0100

As required by legislation in the American Reinvestment and Recovery Act (ARRA), HHS/CMS released rules for the meaningful use of certified EHRs before the end of 2009 (late the afternoon of Dec. 30th). Others have already written plenty on what is actually stated in these rules, therefore, let’s take a look at the potential winners and losers of these new rules as well as those where it is still too early to tell. This analysis will be laid out over the next few posts starting with Winners below. (Source: Healthcare IT News Blog)

Peter Rost Gets A Little Help From The Government

Pharmalot — Thu, 24 Dec 2009 13:46:39 +0100

For those who may not remember, Peter Rost is the controversial gadfly and former Pfizer exec who is locked in a whistleblower lawsuit with the big drugmaker over his allegations that Genotropin, a human growth hormone, was marketed for unapproved uses, such as combating aging in adults and treating short stature in children. Rost worked for Pharmacia, which was bought by Pfizer. Although the US Justice Department failed to join his lawsuit, Rost is pressing on and his case is being closely watched. Last year, he cited numerous instances in Indiana and Kentucky in which Genotropin marketing may have violated the False Claims Act. Providing such detail was needed for the case to proceed and his efforts may serve as a template for other whistleblowers who are stymied by federal judges seekin...

Schering-Plough Pays $21M To Settle Fraud Claim

Pharmalot — Thu, 17 Dec 2009 19:37:18 +0100

The deal resolves allegations the drugmaker “deliberately inflated” the price of its Albuterol asthma med and other drugs, causing California’s Medicaid (Medi-Cal) program to overpay millions of dollars in pharmacy reimbursement, according to California attorney general Jerry Brown. “With healthcare costs spiraling out of control, it’s unconscionable that a Fortune 500 pharmaceutical company deliberately inflated its drug prices to cheat California’s public healthcare system out of millions of dollars,” Brown says in a statement. “This is a company that made more than $12 billion in profits last year, yet still raided the pockets of California taxpayers.” The case began with a lawsuit filed by a whistleblower against several drugmakers...

Court Agrees Whistleblower Suit Should Be Tossed

Pharmalot — Mon, 07 Dec 2009 13:43:46 +0100

A new court ruling may have a significant impact on whisteblower lawsuits that focus on off-label marketing. Last Friday, the US Court of Appeals for the Eleventh Circuit in Atlanta upheld a dismissal of a 2004 lawsuit filed by two Solvay Pharmaceuticals sales reps, who alleged the drugmaker caused the federal government to overpay by promoting off-label use of its Marinol treatment for chemotherapy patients (background). Specifically, the court ruled the reps’ lawsuit was lacking because they failed to offer specific examples showing Solvay actually caused the federal government’s Medicaid program to overpay by millions of dollars based on an alleged off-label marketing. Instead, the reps argued there was an obvious increase in Marinol scrips and a subsequent rise in federal g...

Abbott Labs Probed Over Depakote Marketing

Pharmalot — Fri, 06 Nov 2009 19:58:32 +0100

As they say: another day, another probe into a drugmaker. The latest - the US Department of Justice is investigating Abbott’s sales and marketing activities of the pill, which is used to treat bipolar disorder, seizures and migraines, according to its quarterly filing with the US Securities and Exchange Commission for Depakote. The government wants to know whether the drugmaker violated civil and/or criminal laws, including the Federal False Claims Act, the Food and Drug Cosmetic Act, and the Anti-Kickback Statute in connection with Medicare and/or Medicaid reimbursement to third parties. An Abbott spokeswoman tells Dow Jones that the drugmaker is cooperating, but declined further comment. And a spokesman for the US Attorney in the Western District of Virginia, which is handling the prob...

War Stories from the Medical Billing Advocate Battlefield

Aging with Grace CareConnection — Thu, 08 Oct 2009 22:31:00 +0100

by Sheri SamotinToday was a very interesting session at the Medical Billing Adovcates of America's (www.billingadvocates.com) annual workshop. We spent the day hearing interesting speakers from the Florida Attorney General's office talk about fraud and abuse as it applies to medical billing. We also spent time with an attorney who specializes in helping patients fight with their insurance plans and providers.There seems to be no end to the tactics that providers, especially hospitals, will go to in order to capture extra dollars from payors and patients. They will try to charge for the drapes and gowns in the operating room, even though they are already being paid for the use of the OR and are supposed to include (or "bundle") those items into the facility fee. Or, I'm sure you've heard th...

Brain/ Cognitive Enhancement with drugs... and cereal?

SharpBrains — Mon, 27 Apr 2009 00:59:05 +0100

Several recent articles and news: Brain Gain: the underground world of “neuroenhancing” drugs‎ (The New Yorker) - "Alex remains enthusiastic about Adderall, but he also has a slightly jaundiced critique of it. “It only works as a cognitive enhancer insofar as you are dedicated to accomplishing the task at hand,” he said. “The number of times I’ve taken Adderall late at night and decided that, rather than starting my paper, hey, I’ll organize my entire music library! I’ve seen people obsessively cleaning their rooms on it.” Alex thought that generally the drug helped him to bear down on his work, but it also tended to produce writing with a characteristic flaw. “Often, I’ve looked back at papers I’ve written on Adderall, and they’re verbose. They’re belabo...

Brain Fitness Survey: We Need More Brain Awareness Weeks!

SharpBrains — Wed, 18 Mar 2009 03:04:01 +0100

If you subscribe to our monthly newsletter, you may remember we ran a survey in January. Well, the response rate and the quality of the responses were nothing short of spectacular, in many dimensions. The responses from over 2,000 participants (out of 21,000 subscribers) reinforce the need for public awareness initiatives and quality information to help evaluate and navigate product claims. I have been presenting the results from one of the questions (see below), yesterday at the ASA/ NCOA (American Society on Aging) event, today at IHRSA (International Health, Racquet and Sportsclub Association), as part of more comprehensive presentations of what is going on in the brain fitness and cognitive health field. An obvious implication for the survey result reinforces the need for brain-related...

I love AFLAC

beth's myeloma blog — Sat, 10 Jan 2009 04:55:54 +0100

Before I got cancer, I made sure I had an AFLAC cancer policy. They’ve been great, and I recommend that anyone who is planning on having cancer enrolls in one of their plans before they get it. The trouble is, you don’t know if/when you might get cancer, so you better just plan for it. Expect the worst and hope for the best, some say. I filed my claim for 2008 a week or so ago and was really surprised when I received a check in the mail for $4600. Something wasn’t right. It should have been $900. I’ve been filing these claims for years, so I knew a mistake had been made. I picked up the phone and called AFLAC. They’re going to investigate it and will send a letter when they figure out what happened. Wouldn’t it be nice if they said it was a rew...

Sanofi-Aventis Whistleblower Claims Dismissed

Pharmalot — Sat, 20 Dec 2008 14:08:35 +0100

A federal court in Chicago has dismissed a federal False Claims Act, or qui tam, lawsuit filed by former Aventis sales rep, who charged the drugmaker with off-label promotion of its Lovenox blood thinner and, in doing so, induced and doctors and hospitals to submit fraudulent Medicare claims. In their 2003 suit, Katy Kennedy, who also filed a retaliation claim, and Frank Matos, allege Aventis, now owned by Sanofi, prompted docs to prescribe Lovenox for atrial fribillation, acute myocardial infarction, mechanical heart valve replacement and other conditions for which the FDA had not approved use. They also charged Aventis paid $34,000 to one pharmacist for speaking engagements and hiring him to keep Lovenox on hospital formularies under his control. In addition, Aventis allegedly gave vari...

Obama Sex Scandal?????

bipolar chicks blogging — Wed, 22 Oct 2008 13:22:17 +0100

Watch the following video. Then, decide whether Obama is getting the black vote because he is black. This is very interesting…… It’s no secret that I’m not for the thug from Chicago. He lies and he makes promises to Americans with a big smile on his face. Promises that are dangerous to our country. But, I [...] (Source: bipolar chicks blogging)

Can Bankers Save Doctors? (Can Doctors Save Bankers?) Part II

The HIT Transition Weblog — Fri, 03 Oct 2008 21:40:49 +0100

In Part I of this article, what we might refer to as the "Bad News, Worse News" section, we drew a weather map of the perfect storm of revenue threats that healthcare providers are facing, even as the rest of the economy tanks under tremendous (and one hopes temporary) dysfunctions in the financial sector. Providers are chasing hundreds of patients for revenues that used to come from a single payer; they're being subjected to (whether they are aware of it or not) increasingly sophisticated tools that discount and deny claims, and they're having prior years' settled claims scrutinized for re-adjudication by government and private payers alike. Meanwhile, payers and employers are toying with new quality-based reimbursement models that threaten to move the battle onto a new, unfamiliar landsc...

Peter Rost Wins A Big Round Against Pfizer

Pharmalot — Fri, 03 Oct 2008 19:35:15 +0100

Last February, the controversial gadfly and former Pfizer exec cleared a hurdle in his ongoing whistleblower lawsuit against Pfizer. In a filing, Rost cited approximately 200 instances in Indiana in which Genotropin, a human growth hormone, was marketed by Pharmacia (which was bought by Pfizer) for unapproved uses, such as combating aging in adults and treating short stature in children. Providing such detail was needed for the case to proceed. And the move signaled two potentially significant developments. One is the long-term implication for Pfizer, should Rost ultimately prevail. The other is that his efforts may serve as a template for other whistleblowers who are similarly stymied by federal judges seeking details that are, otherwise, very hard to come by. Interestingly, the Departme...

Can Bankers Save Doctors? (Can Doctors Save Bankers?) Part I

The HIT Transition Weblog — Fri, 03 Oct 2008 17:27:46 +0100

Once-reliable revenue streams are drying up. Money you thought you'd socked safely away evaporates overnight. Your staff starts devoting more and more time to collections, leaving less and less time for day-to-day operations. The things you used to do to pay the bills aren't working anymore, and indications are that you will have to change your business model or go bankrupt. Is this a crisis or a catastrophe? Is it a temporary crunch or a drawn-out recession? Is the source of the problem the stock market, the credit market or unqualified borrowers? If you're a healthcare provider, the answer to all of these questions is "none of the above," because the symptoms I'm describing have nothing to do with the financial crisis everyone else is talking about -- they're a result of permanent chan...

EMR’s Affect on Medical Billing Costs

EMR and HIPAA — Mon, 29 Sep 2008 22:04:03 +0100

I received an email not too long ago from a medical billing company who talks about the crazy costs associated with medical billing. In their email they offered the following statistics on the costs of medical billing. The statistics below represent industry averages taken from the MGMA. Claims Rejected on 1st Submission - 30 % Underpayed Claims - 20% Gross Collection Rate - < 60% Preventable Denials - 90% Denials that are Recoverable - 67% Average days in A/R - 52.32 Cost per claim - $5-$7 Cost per FTE physician - $30,000-$60,000 Cost of billing operations - 18-22% Cost of Billing Personnel - 58-62% Cost of Technology/ Practice Management Solution - 18-22% Source: Avisena whitepaper I must admit that billing is far from my expertise, but it’s a well described necessary evil for almo...

Medical Bankruptcy 2.0 Revisited

The HIT Transition Weblog — Wed, 24 Sep 2008 20:25:52 +0100

Back in December 07, I warned about the delayed impact that January's shift of High Deductible Health Plan enrollment would have on provider revenues. Moving significant percentages of revenue from the difficult-but-predictable insurance plan bucket to the thousand-points-of-non-collection patient-self-pay bucket would take some time to sink in. In fact, I said it might take until July before providers realized they weren't going to get paid for January's care. Hopless Optimism Today, a friend and loyal reader passed along a NYT editorial by Barbara Ehrenreich that suggests the current financial crisis is due in large part to positive thinking, as characterized by the popular film, "The Secret." The financiers simply believed too much in the upside, but that is a matter of course, given t...

Judge Says Whistleblower Suit Should Be Tossed

Pharmalot — Wed, 06 Aug 2008 12:27:46 +0100

A federal magistrate judge has recommended that a federal court dismiss a whistleblower lawsuit brought by two former Solvay reps, who contended the drugmaker concocted an illegal scheme to promote a drug for off-label use and, consequently, caused the federal government’s Medicaid program to overpay by millions of dollars. The drug in question was Marinol, which was originally approved to treat nausea and vomiting for chemo patients who failed to respond to standard meds and, later, anorexia for AIDS patients who suffer considerable weight loss. But Jim Hopper and Colin Hutto alleged Solvay improperly promoted Marinol off-label as an appetite stimulant, because the FDA-approved market was too small. However, in a 27-page report, Magistrate Judge Thomas Wilson of the US District Cou...

New HIPAA Standards Clear Regulatory Hurdle, Approach Flaming Commentary Hoops

The HIT Transition Weblog — Mon, 14 Jul 2008 21:13:45 +0100

Tired of the ambiguities and outdated constraints of the electronic claim, remittance advice, eligibility and other X12 transactions? Help is on the way. Or at least it's coming into view. The enabling regulation to adopt a new version of those standards has cleared the Department of Health and Human Services and has been passed on to Office of Management and Budget for final review. OMB has 30 days to approve it (with or without revisions negotiated with HHS) or reject it. I was fortunate to have the opportunity to participate in some of the X12 workgroups that built the new standards, and am certain that the new standards will improve efficiency and reduce the number of customizations and workarounds. We won't be able to say goodbye to those nasty Companion Guides, bu...

So Many Whistleblowers, So Little Time

Pharmalot — Thu, 03 Jul 2008 12:14:26 +0100

More than 900 cases alleging that government contractors and drugmakers have defrauded taxpayers out of billions of dollars are languishing in a backlog that has built up over the past decade because the Justice Department cannot keep pace with the surge in charges brought by whistleblowers, The Washington Post reports. The issue is drawing renewed interest among lawmakers and nonprofit groups because many of the cases involve the wars in Iraq and Afghanistan, rising health care payouts, and privatization of government functions - all of which offer rich new opportunities to swindle taxpayers, the Post writes. Since 2001, 300 to 400 civil cases have been filed each year by employees charging their companies defrauded the government. But under the cumbersome process that governs these cas...

NPI+Taxonomy = Crosswalk or Chaos?

The HIT Transition Weblog — Mon, 30 Jun 2008 21:45:25 +0100

Are you a provider having trouble meeting the Provider Taxonomy requirements of one -- or several -- of your payers? Are you a payer learning the hard way that the Taxonomies you ask for and the ones you actually get are many miles apart? If it's any consolation, you're not alone. But now, there's hope....Why Taxonomy Matters More Than EverIn the national NPI survey we conducted at the end of April, 57.1% of health plans included Billing and/or Pay-to Taxonomy code (i.e. a Taxonomy for the submitter) as part their crosswalking strategy. 50% reported they would include Taxonomy in the logic to match secondary providers (i.e. Rendering, Attending and/or Referring Providers) to their legacy records. In other words, many payers are expecting taxonomies to be submitted in a way that makes se...

Did Schering-Plough Properly Review Organon Deal?

Pharmalot — Mon, 30 Jun 2008 12:54:36 +0100

That’s the question raised in a motion filed by the drugmaker’s lawyers in a whistleblower lawsuit in federal court in New Jersey. The case, which has actually been kicking around a few years, was recently unsealed and centers on the fatal side effects associated with a neuromuscular blocking agent known as Raplon that Organon withdrew in 2001. (Here’s the background). A former Organon employee alleges that Organon failed to disclose to the FDA concerns about serious bronchospasm that were cited by Raplon clinical trial investigators prior to the drug’s launch in 1999. And the employee, Jeff Feldstein, has added Schering-Plough as a defendant since the drugmaker recently paid $14.3 billion to acquire Organon. Here is the Schering-Plough motion. In arguing the suit shoul...

We Will Help You With NPI Crosswalk Problems

The HIT Transition Weblog — Sun, 15 Jun 2008 19:42:20 +0100

If you came here looking for free information about your NPI problems, you will find lots of it. Click here for about 100 or so articles we've posted on the subject in the last three years. If you need more help than that, we, we'd like to help you, too, if we can. For the past couple weeks, we worked on a concept to develop a "Crosswalk Coach" service that we could streamline and offer at a bargain-basement price to help the small clinics and others who were looking at years and months of Medicare denials. Michael even drew up a clever superhero character to represent the guy who would get you safely across the street. We had to abandon the concept. There are no cookie cutter approaches to this problem. We've learned that some providers are simply in a catch-22 situatio...

Peter Rost vs. Pfizer: The Feds Back His Argument

Pharmalot — Tue, 13 May 2008 14:53:49 +0100

Last February, the controversial gadfly and former Pfizer exec cleared a hurdle in his ongoing whistleblower lawsuit against Pfizer. In a filing, Rost cited approximately 200 instances in Indiana which Genotropin, a human growth hormone, was marketed by Pharmacia (which was bought by Pfizer) for unapproved uses, such as combating aging in adults and treating short stature in children. Providing such detail was needed for the case to proceed. And the move signaled two potentially significant developments. One is the long-term implication for Pfizer, should Rost ultimately prevail. The other is that his efforts may serve as a template for other whistleblowers who are similarly stymied by federal judges seeking details that are, otherwise, very hard to come by. Pfizer, however, last month tu...

Medicare's Wrong... No Willy Nilly NPIs

The HIT Transition Weblog — Tue, 06 May 2008 17:30:09 +0100

We wanted to know whether Medicare's demand that an NPI be placed in secondary provider slot, even if it's the wrong one, was really the right thing to do. Our question to the official standards body was dead simple: In Medicare's guidance to its billers, it states: "If, after several unsuccessful attempts to obtain the NPI from the ordering, referring, attending, operating, other, service facility provider, or purchased service provider; CR 5890, from which this article is taken, requires that (effective May 23, 2008) the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields." (MLN Matters Number MM5890) Using an ID/name other th...

Whistleblower Lawsuit Filed Over Baycol Fraud

Pharmalot — Fri, 25 Apr 2008 17:41:10 +0100

The suit was brought by Laurie Simpson, a former Bayer strategic research analyst who joined the drugmaker just after the controversial cholesterol pill was launched in 1998, and she accuses Bayer of violating the federal and state False Claims Act. The suit was initially filed last year in US District Court in Newark, New Jersey, and was just unsealed. [WHOOPS: We initially wrote the feds joined the suit, but in fact, the US Attorney has declined to do so.] The lawsuit alleges that over a three-year period, prior to its withdrawal from the market, Bayer engaged in illegal and deceptive marketing practices in selling the Baycol cholesterol pill, which was later withdrawn due to side effects, predominantly rhabdomyolysis, a severe weakening of the muscles. Numerous death and 1,600 injuries ...

Dr. Stephen Barrett of Quackwatch to appear on Health Now

Dr. Z's Medical Report — Tue, 22 Apr 2008 19:53:43 +0100

Readers of my scambuster reports will want to listen in to our upcoming interview with Dr. Stephen Barrett, founder of the critically important Web site Quackwatch.com. On April 30, 2008, our show Health Now with Judy Foreman will be talking with this pioneering and tireless exposer of health quackery, frauds and scams. You can register for this free program at Health Now. Health Now with Judy Foreman is our weekly live Internet webcast (formerly called HealthTalk Live) in which we explore a wide range of issues and concerns that affect anyone touched by a chronic illness. Health Now features expert guests and listener phone and e-mail questions, and the discussion is always informative and free-ranging. Listen every Wednesday at 8:30 p.m. Eastern/5:30 p.m. Pacific, and check out the progr...

Former Wyeth Employees File False Claims Suit

Pharmalot — Fri, 29 Feb 2008 18:02:27 +0100

Two former Wyeth employees accused the drugmaker of making false claims to the government in connection with alleged manufacturing problems with its Prevnar vaccine. Anthony Sokol and Mark Livingston filed a whistleblower lawsuit against Wyeth in November 2006 in federal court in Virginia, according to Wyeth’s annual report (see page 62). The lawsuit alleged false claims were made to the government from 2000 through 2005 in connection with the manufacture of Prevnar, a vaccine given to children to prevent meningitis and other infections. Prevnar had $2.4 billion in sales in 2007. A Wyeth spokesman told Dow Jones that company policy is not to comment on pending litigation. The lawsuit had been filed under a federal law that allows whistleblowers to collect a portion of any settlement ...

If the HISsies Fit...

The HIT Transition Weblog — Fri, 08 Feb 2008 21:30:27 +0100

We're dang sorry we won't be at HIMSS08 later this month. Not because we want to run the gauntlet of HIT vendor account execs (tip: If "I'm just a consultant!" doesn't work, tell them you're an investigator from the SEC). No, we're just sorry to miss Mr. HIStalk's party Monday night. But if you're going, we definitely want to extend you his invitation. (Source: The HIT Transition Weblog)

Merck To Pay $670 Million Over Medicaid Fraud

Pharmalot — Thu, 07 Feb 2008 20:41:47 +0100

The drugmaker failed to pay the appropriate rebates to Medicaid and other goverment health care programs, and also paid kickbacks to doctors and hospitals to induce them to prescribe various meds. The allegations were brought in two separate lawsuits filed by whistleblowers under the False Claims Act. Merck has also agreed to a Corporate Integrity Agreement, which means good behavior is now required for the next five years. “Not only is the combined recovery in these two cases one of the largest healthcare fraud settlements ever achieved by the Justice Department,” says Attorney General Michael Mukasey, in a statement, “it reflects our continuing effort to hold drug companies accountable for devising pricing schemes that deliberately seek to deny federal health care programs the same...

Peter Rost Vs. Pfizer: The Evidence Comes In

Pharmalot — Mon, 04 Feb 2008 16:08:32 +0100

Last November, the controversial former Pfizer exec won a significant victory when a federal appeals court ruled that his whistleblower lawsuit against the drugmaker should proceed. A federal judge had previously dismissed the case because Rost “failed to plead his fraud claims with sufficient specificity,” a reference to rule 9b, a provision of the False Claims Act that requires particular info about false claims submitted to the government for payment. This might include amounts charged, drugs prescribed, patient diagnosis and individuals involved in billing. Given the level of detail required, however, winning the reinstatement looked like the easy part, because the info contained in Medicaid databases may compromise patient privacy. Last week, for instance a whistleblower lawsu...

Medicare to Plug NPI Hole with HIPAA Violation

The HIT Transition Weblog — Mon, 28 Jan 2008 21:29:25 +0100

I'm afraid to go back to Baltimore. I've enjoyed a long and fairly collegial relationship with the folks inside CMS, both on the regulatory and the Medicare side of the department. Sure, I've challenged them on occasion, and we sometimes have agreed to disagree, but we tend to agree that we are, after all, pulling in the same direction in our own particular way. They as the regulatory body that oversees an entire sector of the industry and the largest health plan known to humankind; I as a humble IT analyst and blogger from Tulsa, OK. Everything was fine until Medicare NPI. We understood each other. A Cyclops Has No Depth Perception But recently I had to go out and poke them in the eye. I'm not sure if they noticed, but it seems they blinked, one way or the other. And the blink is worse ...

Red Tuesday: Jan 1 2008

The HIT Transition Weblog — Mon, 17 Dec 2007 22:15:57 +0100

On our Black Swans list for 2008, one of the biggest birds will swoop in on the very first day of the year: January 1. That's when a huge number of health plan enrollments roll over, and the move to the High Deductible Health Plan model is going to hit providers hard in the pocketbook. Hence our suggested name for the eventful date: Red Tuesday. Forecast for the Rich: RicherThe Nashville Business Journal cites unnamed analysts in guessing 2009 HDHP enrollment will double from January 2007's 4.5 million. But one named analyst is more specific, calling HDHPs "the best idea I've seen for a health plan in 25 years." I guess that's great news if you're a health plan. The Doctor Will See You Now, Mr. Wimpy Will providers notice? Not from what I'm hearing. ...

The Extraordinary Claim of the Autism Epidemic

Autism Vox — Thu, 06 Dec 2007 22:36:48 +0100

It is too true in discussions about autism: Plus ca change, plus c’est la meme chose. On the one hand, new developments in research about autism—-as a study published today in Neuron about how the lack of the synapse-inducing protein CASK may be associated with autism—are regularly reported. This year also saw the publication of new studies about autism genetics and a continued focus on the environment and autism, in an April workshop on this topic at the Institute of Medicine; the myth of the autism epidemic: Is there something, such as an environmental factor—-thimerasol from vaccines, toxins from the environment, that is causing the increase? How do “changing criteria” contribute? Notes the Scientific American article Two recent studies buttress ass...

Is 5010 a Year?! Why HIT Standards Take So Long...

The HIT Transition Weblog — Thu, 06 Dec 2007 21:55:47 +0100

You thought I was just being clever last week when I quipped, "These umbrage-and-edit timelines rachet out to make the electronic claim standards developed three years ago available for widespread adoption sometime after the the turn of the decade, even with optimistic dependency scheduling." Oh, no. I had inside information. And that information became public this week. The North Carolina Healthcare Information and Communications Alliance and The Workgroup for Electronic Data Interchange have been working on a real live MS-Project-based timeline to show regulators and industry analysts just how much time is consumed in developing, adopting and implementing HIT standards. The equation for the 5010 version of the electronic claim and other ASC X12 administrative transaction adds up to 2014...

Hospital Overbilled You? Errors? Medical Claims Advocates Review Hospital Bills

The Caregiver's Beacon - Resources, Links, Ideas, News — Thu, 15 Nov 2007 22:19:00 +0100

At Medical Claims Advocates you can get ideas for action when there is an error on a medical bill. At CNN Money an article titled "Five Ways to Cut Your Medical Costs" by Cybele Weisser said that errors occur in 80% of medical bills. One of the suggestions the article made is to use a Medical Claims Advocate who can review your medical bills for a percentage of the money saved. A website at the Health Rights Hotline provides Independent Assistance for Health Care Consumers, and has suggestions for when medical billing problems occur or are suspected.An acquaintance in his mid-seventies told me today about receiving a $600 bill from a hospital this week, for three procedures, with three different dates. He had been given treatments at a hospital after he fell while fishing in a river and cr...

HIT Forums Point the Way for 2008 (Part 1 of 2)

The HIT Transition Weblog — Wed, 14 Nov 2007 21:04:19 +0100

The Collaborative Communications Summit is a boutique conference for C-suiters. The concept is to put the event in a tony venue that pampers the executive appetite and bring in a raft of brilliant speakers and those who move and shake the industry. Last week’s CCS topic, “Transforming Healthcare through Health Information Technology,” was enough to pique my interest when I read about it a few months back. When the conference organizers offered us a media sponsorship that included a free press pass, we jumped on it. I was already going to be in LA to speak at the Blue Cross Blue Shield Association's Blue Health IT Symposium, so I could make the CCS event for the price of a couple nights at the hotel. How much could that be? (Source: The HIT Transition Weblog)

Pharma Fines Are Filling The Treasury

Pharmalot — Fri, 02 Nov 2007 13:17:05 +0100

Drugmakers aren’t the only ones, of course. But the Justice Department says it obtained $2 billion in settlements in fraud cases during fiscal year 2007, with most of the recoveries resulting from whistleblower lawsuits, the Associated Press reports. Approximately $1.45 billion of the settlements resulted from whistleblower lawsuits in fiscal year 2007, which ended Sept. 30, the department said. The individuals who filed suit were awarded $177 million. Under the False Claims Act, whistleblowers can sue companies or individuals that they believe have filed fraudulent claims with the federal government and, if successful, they can receive from 15 percent to 30 percent of the proceeds, the AP notes. Health care fraud accounted for most of the settlements, with $1.54 billion stemming fro...

Will RTA Keep Primary Care Providers Engaged?

The HIT Transition Weblog — Tue, 16 Oct 2007 18:44:31 +0100

One of the things that jumped out at me during last week's ASC X12/WEDI Real Time Adjudication Conference was that the consequences of high deductible health plans was going to affect certain provider settings much more severely than others. The push to make patients responsible for a larger component of their health care spending makes sense to employers, who see the immediate consequences of the choices are making today. The long range impact of those choices doesn't necessarily play into such calculations, given the transient nature of the modern workforce. Be Very Afraid Providers are -- or should be -- scared to death, because patients are notoriously negligent in paying their medical bills. Moving a large percentage of your revenue from the conflict-ridden but semi-reliable private p...

Real Time Pilot Shows $6-8 per Claim ROI

The HIT Transition Weblog — Mon, 01 Oct 2007 15:53:47 +0100

A story in Healthcare Finance News reports on several Real Time (Claims) Adjudication (RTA) projects, including Blue Cross Blue Shield of Tennesee, Humana and Cigna. Humana’s pilot, involving a 10-physician practice in Texas, yielded savings of $6 to $8 per claim. “The site saved $14,000 in billing costs alone,” said Janna Meek, director of Humana’s integrated provider solutions. Tennessee's anectodal evidence is also persuasive: One provider reported being able to collect 70 percent of patient-owed fees from those covered by high-deductible health plans when patients were checking out. But, as the piece points out, the standards are not there yet: "Although the technology strategies vary, payers are either starting or expanding pilot programs that adjudicate claims in real time fo...

Aetna, Ingenix a Bigger Deal?

The HIT Transition Weblog — Fri, 21 Sep 2007 18:47:28 +0100

I just got my hands on a copy of the press release detailing the agreement between Aetna and Ingenix. Turns out, it's much more than standards-based Real Time Adjudication (RTA), as if that weren't enough. The payer will be using the EDI testing and validation technology enabled by Ingenix's Claredi division to automate direct connections. Is it possible that the payer finally acknowledged the plainly-stated regulatory requirement that they provide free claims submissions to providers capable of conducting standard transactions? Or did they just want to cut their monthly Emdeon bill? No matter, they're going to be giving providers a host of new, valuable services. Read on....Looking for DirectionPart of the deal involves Ingenix's development of a direct-connect p...

Aetna, Ingenix Partner for Real Time Claims

The HIT Transition Weblog — Fri, 21 Sep 2007 17:34:36 +0100

Aetna and Ingenix have inked a five year deal to implement Real Time Adjudication through an Ingenix portal. The wording of the release suggests that they might be doing this as a true standards-based RTA system, rather than the Direct Data Entry (DDE -- aka "Duplicate Data Entry") that others have deployed. If so, Ingenix could be positioning itself to be an "all-payer" RTA service. Will provider vendors be smart enough to ping one-off 837 transactions and to catch the replies in whatever format they might see? The competitive advantage of enabling same-day collections suggests that some will....http://hittransition.com/flashpoint/ad_rta.htm (Source: The HIT Transition Weblog)

How Might Information Technology Actually Change Health Care?

The Doctor Weighs In — Thu, 20 Sep 2007 04:31:08 +0100

Brian KlepperToday I’m in San Francisco for the Health 2.0 conference, billed as “User-Generated Health Care.” Organized by my pal Matthew Holt and his partner, Indu Subaiya, "Health 2.0" references "Web 2.0," social networking, applied to health care. The meeting will feature top executives from high and low profile IT firms that either are already dedicated to or hope to play an important role in health care, like Google, Microsoft, Yahoo, Intel, Cisco, WebMD, Revolution Health, AthenaHealth, Sermo, and many other lesser known organizations, all discussing their strategies for leveraging data in new ways to create value for all health care constituencies.Elsewhere, I’ve referred to this as a “significant portion of market-based heal...

The Wal-Mart Effect on Healthcare

The HIT Transition Weblog — Wed, 19 Sep 2007 10:52:23 +0100

Once again, the Mr. HISTalk site has me thinking. This time, it's a reader's forum post on the possible impacts of Wal-Mart's entrance into the health care delivery market. A fellow calling himself Art Vandelay lays out some pretty thoughtful possibilities. His narrative investigates every aisle of inquiry, from the push toward transparency in pricing and wait times to the impact a nationwide, HIT-enabled provider network could have on road warriors strapped with high deductibles and a runny nose. As a neighbor (the Behemoth of Bentonville is a short drive from Tulsa, close enough that we can hear it breathing at night), I've long been intrigued by the Wal-Mart Effect and the impact it might have on US healthcare. Not just as an entity, but as a model of monopsony: The dominant influence t...

Upcoming Travel and Speaking

The HIT Transition Weblog — Tue, 18 Sep 2007 19:30:53 +0100

Sometimes I lose track of myself. I know I don't share everything on this blog. Like my work on the new standard Health Identification Card implementation guide is something I've never blogged about, even though I've devoted a fair amount of time to the WEDI effort over the past 18 months. I'm going to try to be a better correspondent. I do a lot of speaking engagements, and it's usually something I care about (not often something I'm selling, which makes things interesting). Here's what I have on the agenda for the near future. WEDI/X12 Conference on Health Savings Accounts and Real-Time Adjudication October 9-12, Vienna, Virginia (schmoozing) Collaborative Communications Summit November 5-6, Beverly Hills (pressing) 2007 Blue Health IT Symposium November 7-9, Los Angeles (speaking 11/7: ...

Medicaid Plans to go NPI?

The HIT Transition Weblog — Mon, 17 Sep 2007 22:06:53 +0100

On today's WEDI NPI call, several different sources talked about various state Medicaids' plans to move to NPI claims processing. As we have cautioned, the CMS Contingency announcement allows for health plans to move to NPI processing at any time up to May 23, 2008. Plans can and will transition during the intervening months. Some already have. States mentioned on the call -- currently unconfirmed -- include Arkansas (hard cutover Oct 15), California (accepting Oct 1) , Michigan (October schedule may be shifted to February), Montana 10/1, New Jersey 10/3, Oregon Dec 31. Those dates mean nothing until we know what the specifics are in each case. Will they allow dual use submission of NPI plus legacy ID? Is it only the billing/rendering provider loop, or do they expect to see NPIs for attend...

New York City And State Sue Merck Over Vioxx

Pharmalot — Mon, 17 Sep 2007 18:50:07 +0100

The state and city of New York today filed a lawsuit against the drugmaker for allegedly hiding the heart risks associated with the painkiller. The lawsuit, filed in New York State Supreme Court, seeks damages, penalties and restitution for “tens of millions of taxpayer dollars wrongfully spent on Vioxx prescriptions,” New York State Attorney General Andrew Cuomo says in a statement. The suit, which was joined by New York City Mayor Michael Bloomberg, claims that many Vioxx scrips never would have been written if docs were properly informed of the risk of heart attack or stroke. Six other states have filed similar complaints. “Merck’s irresponsible and duplicitous conduct endangered the health of New Yorkers and wasted our tax dollars,” Cuomo says. “As a...

The Ultimate HIT Wonk Blog?

The HIT Transition Weblog — Mon, 10 Sep 2007 21:32:30 +0100

In the "How Did I Miss This?" Category comes my stumbling upon Ed Dodds' Conmergence Blog. I've been told that talking to me about HIT -- or reading my blog -- is like taking a drink from a fire hydrant. If so, then Ed's blog is like Niagara Falls -- not just about HIT, but about distance learning, open source and neologistic categories like Geekonomics, Interoperancy and Politicine. Sometimes his posts are long and thoughtful, sometimes he re-posts public notices, or puts in a two-word recommendation to an external site. Lots and lots of long lists of names, chapters, external links, etc., leave you in a quagmire of thought you wish you had time to slog around in. The net result is kind of like opening up Rain Man's cranium and watching the neurons fire as he counts the toothpicks in slow...

Link to All CMS NPI FAQs

The HIT Transition Weblog — Tue, 14 Aug 2007 15:06:14 +0100

Many moons ago, I wanted to share a query string that would bring up all CMS FAQs that include the term NPI. That was preferable to linking to specific items, because new items were being constantly being added. I did the search query on the CMS site, which created a URL that was a mile long. I systematically eliminated components of the string until I came up with something that produced the desired results, but was only a furlong or two in length. I've given this out before, but I didn't have a direct, isolated link on my blog, so here it is. You can click on the big ugly string, but that often gets broken in pieces when you copy/paste/send via email, so if that's an issue, you can link people to this blog post by copy/pasting the second string. (I don't use tinyurl because I'm not sure ...

Show Me Yours And I'll Show You Mine: Transparency and Health Care Power Shifts

The Doctor Weighs In — Thu, 09 Aug 2007 22:41:34 +0100

Brian Klepper Mention a health plan to doctors or hospital administrators, and they’ll likely bend your ear about how the performance feedback data they get from them are wrong, how their reimbursements are based on inaccurate data, and how they think the inaccuracies are intentional.Because they aggregate huge volumes of claims, health plans have the best patient and provider information. While many providers dismiss claims data as wholly inaccurate, they in fact contain a wealth of useful information about patients and their care that can be teased out using the very sophisticated analytical tools that are now readily available. These techniques permit credible evaluation of the relative performance of doctors by specialty and hospitals by service. Virtually all analytic...

Contest: NPI Dissemination Roulette

The HIT Transition Weblog — Wed, 01 Aug 2007 20:59:35 +0100

An erstwhile reader suggested that, with yet another indefinite delay of the release of the NPPES data, I should open a book on the actual date that CMS will go online with the NPI Registry. I'm sure she's not suggesting anything illegal, so I've devised this simple contest: Email me (martinjensenAThittransition.com) your estimate of when you think the NPI Registry will go online and why you think the date you predict will be the real one. I'll post the most interesting responses in a future blog, though I will keep all contributors' names a closely-guarded secret. FOIA rules do not apply here! In keeping with the spirit of the topic, the end of the contest is indeterminate. I'll quit accepting submissions when the new target date is announced, which could be any minute now. We know that d...

CMS Pulls a Lucy - Dissemination Football Snatched Away

The HIT Transition Weblog — Wed, 01 Aug 2007 15:56:13 +0100

I don't know about you, but I was up at midnight to see whether the promises of the long-awaited data dissemination policy had been actualized. I anxiously clicked on the NPI Registry link and got the following familiar non-information:NPI Registry is currently unavailable. Please try again later. Dissemination Delayed is Dissemination DeniedNo NPI lookup. This morning the message persisted. So I called the technical support number and spoke to an NPI Specialist.CMS has decided to delay the deployment of the registry. It could be next week; it could be longer. They had already decided to delay it until August 1. Does this mean they have decided to delay it again? That is correct.Do I feel like a blockhead? That is correct. This Time, She Really Might Let Me Kick ItUnlike NPPES, we at the H...

We Must Be Stupid, Stupid, Stupid: Mega Life and Health

The Doctor Weighs In — Wed, 01 Aug 2007 11:06:44 +0100

Brian KlepperI’ve filled a lot of airtime and column inches over the last couple years talking about the financial conflicts that characterize so much of health care. I’ve focused on topics like oncology drug rebates, Medicare D drug plan scams and unnecessary care by doctors and hospitals, but the truth is that these unethical and abusive practices abound in virtually every area of health care. These outrages are often glossed over because they’re perpetrated by respectable people presumably working under the mantle of a higher mission. Of course many health care professionals are mortified by these practices and know that the system must change. I recently did a video commentary on financially conflicted care on Medscape and expected a physician backlash. What arrived i...

CMS Moves Dissemination Goalposts, Tees Up for 8/7

The HIT Transition Weblog — Tue, 31 Jul 2007 16:26:33 +0100

Sometime last night, CMS posted a bunch of news to their NPI Data Dissemination page. They must have reconsidered the issue of leaving the first data file out there for perpetuity (including all the privacy-concerned providers who somehow didn't get the previous messages about redacting addresses and numbers they don't want to share). Now they say they will post a fresh file every month. Deactivated provider records will simply disappear. Neat, huh? Guess we don't have to worry our pretty little heads about when a provider was deactivated or why. The posting of the NPPES data file now has been given a definite date of August 7. The link is http://nppesdata.cms.hhs.gov/cms_NPI_files.html In answer to some of the questions you may have... Yes, it will be one big'ol CSV file, accompanied by a...

Medicaid Taxonomy Requirements are Booming

The HIT Transition Weblog — Mon, 30 Jul 2007 20:32:00 +0100

Back in 2004, the NMEH/WEDI Survey on Provider Taxonomy showed that many Medicaid plans and some commercial plans (based on response population) would be looking at Provider Taxonomy codes as part of their NPI remediation strategies. Provider Taxonomy is a 10-character code that indicates practitioners' specialty and/or subspecialty designation, or organizational care setting. It's a situational data element in the 837 electronic claim formats, and up until the time of the survey, had been sparsely employed in its when necessary for adjudication context. Since that time, we've been working to alert the healthcare community about some of the pitfalls of using this poorly understood, but sometimes necessary, code as an NPI tie breaker. So we crammed about four years of research into a 90 min...

Many Americans believe unsubstantiated claims about cancer

The Cancer Blog — Thu, 26 Jul 2007 04:00:00 +0100

Filed under: All Cancers, ResearchA new study from the American Cancer Society shows that many Americans believe scientifically unsubstantiated claims about cancer and that Americans bearing the greatest burden of cancer are the most likely to be misinformed. The study used a nationwide telephone survey. For example, the study found that: Nearly seven in ten Americans (67.7%) said the risk of dying of cancer in the U.S. is increasing. Nearly four in ten (38.7%) agreed that living in a polluted city is a greater risk for lung cancer than smoking a pack of cigarettes a day. Three in ten (29.7%) thought electronic devices, like cell phones, can cause cancer. About one in seven (14.7%) thought personal hygiene products, like shampoo, deodorant, and antiperspirants, can cause cancer...

CMS Lists Common NPPES Mistakes

The HIT Transition Weblog — Thu, 05 Jul 2007 22:48:19 +0100

CMS-the-regulator has rescheduled release of NPI data for the end of July, but has warned providers to update their records by the 15th or risk dissemination of private and/or bad data. Now CMS-the-payer is warning providers of specific problems in their NPPES record that might lead to Medicare crosswalk errors (read unpaid claims). Check it out at MLN Matters SE0725. It's a pretty helpful document, and contains lots of good advice to those providers who don't bill Medicare, too. Also contains useful stuff about how Medicare will map NPIs from 837 Claims to 835 Remittances.... (Source: The HIT Transition Weblog)

Beating cancer, one birthday at a time

The Cancer Blog — Wed, 20 Jun 2007 04:00:00 +0100

Discussions about cancer often include mention of age. We talk about how old someone is at diagnosis, how old a person is at each year of survival, the age of an individual at the time cancer claims his or her life. Age reveals a lot. It dumps us into statistical categories. Most patients diagnosed with gallbladder cancer, for example, are older than 65. Age sometimes predicts prognosis. Young women diagnosed with breast cancer tend to have more aggressive forms of the disease. This can compromise chances for survival. Age also solicits judgments. "You are too young," some people told me after learning I'd been diagnosed with breast cancer.I think about my age all the time. I think about how I was 34 when I found my lump, how I happily arrived at age 35, how I made it to 36, and how today,...

Crosserwocky

The HIT Transition Weblog — Thu, 14 Jun 2007 16:04:43 +0100

An inside story from a provider impacted by the kind of Medicare crosswalk snafu I described yesterday.... (Source: The HIT Transition Weblog)

NPI Jaywalking: UPIN Vacuum Leaves Crosswalks Unguarded

The HIT Transition Weblog — Wed, 13 Jun 2007 21:03:26 +0100

Any time the government discontinues a service -- particularly a free service -- there is bound to be grumbling. Still, as taxpayers, we have to recognize that when the cost exceeds the value, it's important to retire those programs, and the sooner the better. After all, how many billions are wasted every year through the continued funding of once-useful or well-intentioned public services that are no longer needed? When it comes to the issuance of UPINs to Medicare Providers and the free public lookup through the UPIN Directory, though, the recently announced May/September shutdown dates have many crying, too soon! Providers and some other parties (certain private payers, repricers) make the case for a continuing need for UPINs during the transition to NPI. On Monday's WEDI NPI Subworkgro...

Paper Cuts

The HIT Transition Weblog — Thu, 29 Mar 2007 22:37:25 +0100

I keep telling people not to mess with paper. So, while those of us who focus on electronic transactions are trying to work our way through the National Provider Identifier transition, there come a couple of minor news items regarding the new good old paper forms. CMS-15oops!First, the CMS-1500 professional claim form (still commontly referred to as the HCFA-1500, a decade after the Health Care Finance Agency became the Centers for Medicare and Medicaid Services) was found to have a major glitch. The format approved by the National Uniform Claims Committee got some sort of minor tweek by accident, which left the federal to issue its own -- incorrect -- version of the same thing. Looks like millions of copies were printed according to the bad specs, leaving CMS to issue a warning a couple w...

Deleware Medicaid NPI: Little State, Big Bang

The HIT Transition Weblog — Wed, 28 Mar 2007 22:03:07 +0100

For most of the US, the NPI Final Rule becomes mandatory on May 23, 2007, but in the state of Deleware, Medicaid billers have already hit the deadline -- two months ahead of schedule. According to the implementers of the system, this is not news. Delaware Medical Assistance Program's providers have been told for months to expect the early deadline. An admirable number of face-to-face meetings and multiple methods of outreach have taken place. Light-Switch CutoverThe early transition is allowable under the Final Rule -- a fact that CMS has been clear to make numerous times in the past. What disturbs some observers, including this one, is that Delaware's aproach includes no dual use period for transitioning from legacy IDs to NPI. They planned to shut down their legacy system that relies ent...

Jerking around the frail elderly

The Doctor Weighs In — Mon, 26 Mar 2007 17:08:07 +0100

Grandma buys long term care insurance so that she won’t be a burden to her family. Good idea, right? Well, take a look at this article on long term care insurance in the March 26, 2007 NY Times. It will make your blood boil.It turns out that some long term care (LTC) insurers have “developed procedures that make it difficult – if not impossible – for policyholders to get paid.” In California alone, according to the article, nearly one in four long-term care claims was denied in 2005. This sounds more like a gamble than insurance.The article is full of stories about old folks getting jerked around by one LTC insurer in particular: Conseco. According to the NYTs, its subsidiary, Bankers Life and Casualty sent the wrong form to an 85-year old demented woman and t...

The False Claims Act: Recent Changes Affecting Health Care Entities

Health Care Law Blog — Tue, 06 Mar 2007 11:42:00 +0100

Discussion and Analysis, administrators at CMS recognized that the best way to cut Medicare and Medicaid spending and maintain the integrity of the programs was to reduce Medicare and Medicaid fraud and abuse. For example, the Department of Health and Human Services reports that it collected almost $2.3 billion in 2006 from false claims suits. By implementing and actively enforcing anti-fraud compliance laws, the government can recover more money and, thus, curb the amount of Medicare and Medicaid spending. In order to further combat health care fraud and abuse, Congress enacted the Deficit Reduction Act of 2005 (“DRA”), P.L. 109-171. The DRA contains provisions to slow mandatory spending in Medicare and Medicaid. Furthermore, the DRA includes a provision, § 6032, that requires health...

Consumer Directed Health Care and Real Time Claims

The HIT Transition Weblog — Wed, 14 Feb 2007 03:27:44 +0100

Just got done with the first day of the X12/WEDI Real Time Adjudication Conference. Some are now abbreviating this as RTCA (for Real Time Claims Adjudication), What's RTCA, you say? Well, that's one of the questions we're debating. Basically, the concept means the patient walks in, gets treatment and the provider can submit the claim, get the health plan's payment amount (but not necessarily the payment) and the patient responsibility amount -- all before the patient leaves the office. The provider gives the patient the bill and receives payment or at least an accurately quantified promise. The WEDI/X12 conference was just announced a few weeks ago, but there are a couple hundred movers and shakers here in Reston, Virginia. Why the sudden interest? In an acronym, CDHC: Consumer Directed He...

False Claim Act

symtym — Tue, 26 Dec 2006 05:00:00 +0100

(Source: symtym)