Medicare Wins in Vegas Fraud Case

Rakesh Nathu, a Las Vegas oncologist, settled his fraud case with the Justice Department yesterday for $5.7 million plus interest. Dr. Nathu was accused of submitting false claims to Medicare, TRICARE and the Federal Employees Health Plan for various radiation oncology services, including intensity modulated radiation therapy, and double billing for services. We hope he did better at the craps table. The government has recovered more than $7.3 billion in False Claim Act cases since 2009.

Among CarePrecise clients are law enforcement agencies working on federal and private payer fraud investigations. As a result of work done for our clients, we developed a means of matching the federal fraud conviction list with providers' NPI records, and associating certain demographic data with practice locations to help visualize patterns. Late in 2010 we began including the fraud data in our CarePrecise Access Complete dataset, and the additional economic data in CarePrecise Gold products. Now included is a flag that indicates provider records whose data strongly suggest a match with the federal LEIE (List of Excluded Individuals/Entities) database. Other features help investigators track providers' licensing, credentials, specialty codes, enrollment in the PECOS database, and numerous other functions.

Read the Justice Department news release.

New Way to Market to Healthcare Providers

The international PR firm Ogilvy has just released a study prescribing a shift in healthcare marketing from the exploitation of clinical breakthroughs to something Ogilvy calls "sustainability." They're not talking about the sort of sustainability we in healthcare usually mean, such as the sustainability of a health information exchange's business model. Instead, they're suggesting that we start selling green.

Companies with strong environmental competencies will rule the market in the coming years, say the investigators, Jeff Chertack and Monique da Silva. In an op-ed by Chertack, he says that "[the new] value will be delivered by new healthcare products and delivery systems that help society adapt to and thrive in changing climate and disease patterns."

CarePrecise Technology made a move in the past year toward eliminating a large part of its carbon footprint by shifting even our largest file deliveries from physical (DVD disks) to virtual. All new product sales are now 100% virtual, and as subscribers renew, their deliveries will be virtual as well. Not only has the shift reduced fuel and materials consumption, but products are now delivered in less than half the time. In a business where the freshness of data is crucial, every hour counts. CarePrecise's NPI directory unit, NPIdentify, has produced state NPI directories in electronic form only since 2007.

CarePrecise's data center is a shared environment, utilizing hyper-efficient cloud computing resources. Except for certain mission-critical operations performed on in-building platforms, all front-end operations and many back-office computing tasks have been moved to the cloud, dramatically reducing office space utilization and fuel consumption.

Whether the healthcare industry in specific, and the broader business community in general, will effectively turn environmental competencies into profits is still an open question. Certainly, entities like hospitals make huge impacts and consume enormous resources (think about all those disposables and all those sheets washed after 30 minutes of use, pillows, trays and pitchers discarded after each patient...), and spectacular improvements could be made. Vendors who help these organizations green up are offering a new way to compete for patients. The competitive advantage offered by corporate carbon consciousness could be tomorrow's marketing edge for providers and their vendors.

Flaw in CMS Logic Causes Cost

When the NPI Final Rule (and all of its after-final rules) created the National Plan and Provider Enumeration System, there were many unknowns: Which datapoints would be released for the industry to use? loomed large. But another issue has come home to roost.

Organizations (Type 2 providers under the rule) were permitted to have as many NPI numbers as they liked, and they could structure their assignment of NPIs any which way. For instance, one hospital might get separate NPI numbers for each of its business units, while another got and NPI for each of its physical locations, another for each of the cluster of corporations, while some clever hospitals got an NPI for each reimbursement channel. And then of course, some hospitals got just one.

No problem with that -- the various business optimization strategies are interesting to observe, and surely make sense in their various contexts. The problem is that there is no primary NPI number per hospital or health system. That is to say, there is no way to know from the NPPES records which if any of the NPI records is a parent, and which is a child. Oh, of course, an army of human analysts can pore over the records and find 37 hospital NPI records each identifying, say, Mayonaise Health System as its parent. But a computer finds that task a bit difficult, since it will find many variations in the records, e.g.,

• Mayonaise Hospital
• Mayonaise Health System
• Mayo Hospital
• Mayo Hospitals
• Mayonaise Hospitals
• Miracle Whip Health
• and on an on

Thus, it becomes essentially impossible to say how many hospitals there are, even though we are looking at the complete set of federal records on hospitals. Had there been a primary or master NPI required for each General acute care hospital -- regardless of how many business units and other NPIs are involved, it would be possible to perform much more significant research on hospital service areas, densities, availability of care, duplication of services, and much more. (We've just started putting state-by-state physician and hospital counts on our home page at CarePrecise.com, but for now, we are able only to show the total of all hospital records -- 29,946 at present -- which is far more than the roughly 5,000 actual hospitals to whom all those records belong.)

The coyness built into the NPPES was more or less deliberate. American hospitals are a contentious lot, engaging in constant competition, and they did not want any more known about them than absolutely necessary. Coy data costs everyone money, and adds opacity to the healthcare system. Still, with the HospitalCompare project and our subsequent mining of all of these data sources, much can be learned, and the reach of each hospital organization can ultimately be published. Stay tuned.

Ryan Plan Dies in the Senate

"The Republican plan to kill Medicare is part of a plan to balance the budget on the backs of seniors," Senate Majority Leader Harry Reid said before yesterday's vote. That plan, originating in the House authored by Republican Paul Ryan, would have dismantled Medicare guarantees in favor of a private system that would force seniors to shop for health plans.

Republicans forced a vote on the Obama Administration's budget as a ploy to show the lack of support among Democrats for it. The 97-0 vote roundly defeated the President's budget.

Health Information Exchange Finance Study

Lately I've been asked by multiple people about the RHIO/HIE work we did a few years ago. With wider adoption of EHR and EMR, health information exchanges are finally beginning to be able to sink their teeth into data, and their value is being better understood. Still the most detailed analysis of HIE finance is the two-year study conducted while I was senior analyst at Healthcare IT Transition Group. The full 129-page study is now available online again.

New Hospital Admin Education Website

Hannah Anderson's goal was to compile an unbiased and updated list of every school that offers a hospital administration degree in the US.  She felt that the existing lists were not comprehensive, easy to find, and many websites have outdated information and links. www.HospitalAdministration.org is a valuable new resource for hospital administration students, and for seasoned administrators when we're asked to make recommendations. All the schools are listed on the front page and lead directly to each program, and can be viewed state-by-state. Thanks, Hannah!

Got Teeth? Here Comes HIPAA Enforcement

Two-day workshops in April, May and June have been set to train state attorneys general in HIPAA enforcement. The economic stimulus law attached stronger penalties for HIPAA privacy and security violations, and perhaps more importantly, removed sole prosecutorial powers from the Office for Civil Rights at HHS (OCR) for enforcement of federal privacy and security provisions by granting dual enforcement authority to state attorneys general. Going further, the law also expanded application of HIPAA criminal provisions to any individual who obtains or discloses health information kept by a covered entity -- not just the covered entity itself -- which essentially reverses the Bush administration Justice Department, which held that only "covered entities" are eligible for prosecution. So, if that EHR software company has an oopsie with your medical records, your state attorney general can go after it. CHOMP! Read the Modern Healthcare article.

Patients Want Their Providers Online

The second-annual study from Intuit Health, the Health Care Check-Up Survey, found that 73% of Americans surveyed would use secure online tools to access lab results, request appointments, pay medical bills, and communicate with their doctor's office. CarePrecise began building web portals for healthcare providers a few years ago, and has seen a rise in interest from providers, who want to be able to point patients to written information in the controlled environment of their websites. Providers are also looking at adding scheduling applications, and some are participating in PHRs (patient health record portals). Read the Information Week article.

Good News, Docs and Vendors: No Medicut

According to the Associated Press, the Obama administration proposes $3.73 trillion for the next budget cycle, as part of its plan to shrink the federal deficit by $1.1 trillion over the coming decade. $62 billion of the savings would be used to avoid cuts in Medicare payments to physicians over the next two years. The full proposed budget is expected to be released later today.

Nearly 3000 Excluded Providers Still Practicing

You might wonder if, and if so, why, healthcare providers who have been convicted of Medicare fraud are still practicing medicine, writing prescriptions, and billing health plans (except, presumably, Medicare). Well, it's a good question. Apparently such a conviction may not get a provider's NPI deactivated.

For several months the number of providers that appear on both the HHS Office of Inspector General's excluded providers list and the current National Plan and Provider Enumeration System (NPPES) have hovered around 2,700.* But for December the number jumped to 2,925. Of that number, more than 1,400 are physicians.

For the past several months, CMS has dropped only 400 to 500 providers each month for various reasons; not all dropped NPI records are due to fraud convictions. Interestingly, the December NPPES dropped more than 1,000 records, while still including more than 2,900 providers listed in the LEIE (List of Excluded Individuals/Entities), the federal database primarily of healthcare providers convicted of fraud or other crime, for patient neglect or abuse, felony controlled substance conviction, or whose licenses have been revoked, suspended or surrendered. A small number of providers are included on the list for less serious reasons, including refusal to provide required information to HHS, and default on a federal healthcare education loan. An inquiry sent to CMS requesting information on the matter has not been answered.

Each month, nearly 30,000 new records are added to the NPI database, primarily representing new healthcare providers. On average, 33,000 records are updated (by the providers themselves in nearly every case). The December NPPES database includes 3,277,833 healthcare provider records. All HIPAA-covered U.S. healthcare providers are required to obtain an NPI record. For all practical purposes, a physician's NPI number, along with a DEA number, is required to write a prescription because pharmacies generally require them. Theoretically, at least, if a pharmacy could not find a valid NPI number, it could refuse to fill the prescription.

CarePrecise compiles federal healthcare provider data for use in research, clinical trial provider pool development, fraud prevention and marketing. Clients include health plans, educational institutions, drug companies, marketers, law enforcement, health systems and individual providers.
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* Source: CarePrecise research data. Methodology involves cross-referencing the two databases using proprietary algorithms to affix NPI numbers to providers in the fraud database; the fraud database (LEIE) does not include NPI numbers, making it difficult to track against practicing providers. Actual number of providers on both lists may be higher; the cross-referencing algorithm is used conservatively.

All Your Words Are Belong To Us

Your phone-to-phone text messages are secured against being read by hackers using a decades-old technology that is full of holes and regularly being hacked. As is your location, any time you have your phone turned on. And it's not just the phone companies, not just law enforcement using $50,000 network sniffing devices. It's hackers using $15 cell phones and a laptop. In a demonstration at the Chaos Computer Club (CCC) Congress a few days ago, a couple of seasoned pros gave the assembled hackers a step-by-step tutorial.

But wait, you say, how come hackers aren't cracking the phone companies' SIM card codes so I can do stuff like, say, run an iPhone on my Sprint account? Well, that's because the phone companies are using much tougher encryption to lock in their revenues than to secure your private information. “There is one key used for communication between the operators and the SIM card that is very well protected, because that protects their monetary interest,” says Security Research Labs researcher Karsten Nohl. “The other key is less well protected, because it only protects your private data.”

The problem stems from laziness. The companies could almost effortlessly make two or three changes to tighten up security, firstly, to follow their own industry standards that have been in place for many years. Rather than sending random data in the constant "Are you there?" messages sent to your phone, they use plain text, making it easy to find you and connect a phone with specific data traffic. There is no reason whatsoever for this negligence, but the second step might require a bit more programming, namely, to stop the practice of reusing security keys over and over, making it easy for a hacker to run through a few keys and quickly tap into your session. The fix would probably take a programmer a couple days and cost your phone company a whopping few hundred bucks. Multiplied by several phone companies, the astronomical price of securing hundreds of millions of phones - yours, mine and everybody else's - would run in excess of a few thousand dollars.

Okay, maybe that's a low-ball. Check out the article at ars technica.

Marketing: Top 5 Web Trends for 2011

Even in this economy, price competition isn't the answer. It can eviscerate the bottom line, and associates our brand with bottom feeders.  Instead, in 2011 marketers will be learning to give something else to our prospects and customers.  Social media, content push, convergence, social objects and service -- these five emerging trends are covered in an article on OpenForum.com, and I hope you'll read it. But here's the gist:

1. Social Media. No, it's not Socialism. Yet. But the communities aggregated by Facebook are the 2011 equivalent of proletariat power. No longer are our gripes and kudos heard by only a few co-workers in the lunchroom, but by hundreds or thousands of our closest friends. And their closest friends. And their closest friends. B2B and B2C marketers are both learning the power of chatter. While waiting for the curtain to rise at a recent entertainment event, audience members all seemed to sort-of know one another. In clusters around the room, it became clear that almost all 150 or so attendees had responded to a Facebook invitation.
2. Content Still Rules, but... We've all learned that developing rich online content is key to getting traffic and building credibility with our market. But much of that content just sits there. We've done the Email Newsletter thing, to push content out to our community. Tweets are the next step, using brief and much more frequent touches to keep our customers and prospects close. And tweets don't get your email domain blacklisted.
3. Converge and Hybridize. There's the web site. And then there's the Facebook page. It's time to pull them together in a seamless environment that makes interaction integral to the web experience of all your visitors. And it's more than just putting an F button on your home page. (What? You still don't have an F button on your home page?)
4. Widgets and Web Tools and Mascots - Oh, My! They're called social objects -- little bundles of clever or cute or useful that get picked up and sent around and pinned to other people's pages. Maybe it's a relevant cartoon or really funky-looking lolcat, or a widget that lets your visitors grab a chunk of your content for their own site or Facebook page. The point is to get other people giving your stuff away for you, just like the sample lady at the grocery store. Only for free; once you've covered development costs, that is.
5. Serving is the New Selling. I can remember the exact day that I decided to start giving extreme customer service. It was just after I'd had a great customer service experience myself, with a vendor that made such an impression on me that I've stuck with them ever since -- three years now. It costs me absolutely nothing to make every customer feel smart, attractive, rich, famous and wanted. The actual content of a service event does use up a little more time, and sometimes I even make a follow-up call (which really blows their minds). But the first result is that I love doing it, and service events have become a true joy, and the ultimate result is that the bottom line proves that it works for the customers, too. Now, instead of spending time calling on leads, I spend my time with customers -- including the ones who are just downloading the freebies or have questions. I still have to get the word out, of course, but I can put more resources into direct mail and web advertising designed just to start a conversation. We're entering an age of smarter selling that's all about creating relevance and utility for our prospects and customers, and we're leaving the age of selling "lifestyles." Now, when we get that first contact, we have to listen for the person's existing patterns, to learn how we can help them get more value from the way they are already doing business, or living their lives. It's not about generating warm fuzzies, but about delivering real value -- the stuff that our price-competing competitors don't have any of.

Do these five ideas all seem to run together? Naturally. Social media has helped to evolve our understanding of content and service. We're learning to be there for our markets, in every sense of that expression, rather than driving the markets to us.