Fraud in the Healthcare System, Part 2: How to make seniors less of a target

Posted by on Apr 21, 2014 in Blog, Legal Nurse Consultant, Medical Conditions/Terminology Blog Series, Services

I wrote recently about fraud and its huge impact on healthcare costs.  It costs you and me $80 billion a year, according to an FBI estimate! Cost, however, can be measured in all sorts of ways.  Consider the emotional and cultural toll fraud takes when you know that the elderly are a prime target.  The other day, I saw that financial scams against the elderly are considered “the crime of the 21st century.”  (Sorry, but this includes you, too, Dad.) Who is targeted and why? Here’s a quick look at two big reasons why our elderly are so often victimized:  Most senior citizens are likely to have a nest egg. This makes them attractive to con artists.  However, low-income adults are also at risk. Most elderly victims were raised to be polite and trusting. Not only are they therefore more likely to comply with their perpetrator, seniors less likely to report fraud because they’re embarrassed. Plus, there are more and more seniors and targets available, as our society ages. What does healthcare elder fraud look like? Here are some of the things to look for: Medical equipment is a big source of potential fraud and abuse.  Watch out when equipment manufacturers offer “free” products.  Insurers are then often charged for products the individual may not have needed or may not have been delivered. “Rolling Lab” schemes are another way our elderly and providers are victimized.  This is when unnecessary or fake tests are given to the elderly at retirement homes, shopping malls, or drug stores and then billed to insurance companies or Medicare.  Sometimes individuals are billed for services never rendered by changing bills or submitting fake ones. Medicare fraud is a biggie as well, and the elderly are frequently targets.  Because physicians must sign documents certifying that equipment or testing is needed before Medicare pays for it, con artists may forge signatures or bribe doctors to sign them.  Once the form is signed, the manufacturers bill Medicare for merchandise or services that were unnecessary or never even ordered. How do we protect the elderly against fraud? Here’s some practical advice, based on years in the field: Keep track of healthcare records and equipment or tests received. Review your explanation of benefits and call for discrepancies or questions. Ask medical providers what your charges will be and what to expect to pay out-of-pocket. Be picky who you give your insurance or Medicare ID to. Be wary of door-to-door or telephone medical equipment salespeople. Don’t give blanket authorization to medical providers to bill for services rendered. Never ever sign blank insurance claim forms. Unfortunately, this is only the tip of the iceberg.  So, stay sharp! Jordan Ilderton, RN, BSN, is...

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Separating Chronic Spinal Injuries From Acute Injuries

Posted by on Apr 7, 2014 in Best Practices, Blog, Legal Nurse Consulting, LNC, Medical Conditions/Terminology Blog Series

Technical Terms Make the Difference When a legal nurse consultant reviews a file, one of the objectives is to identify and separate chronic from acute. This is critical in order to help the claims representative have a clear and precise understanding of what is and is not related to the injury in question. So, when reviewing medical records dealing with a back-injury claim, it’s important look closely for words the radiologist uses to describe the spine.  For example: Desiccation Joint space narrowing Bone spurs/osteophytes Scoliosis Vertebral endplate bone marrow alterations Osteochondrosis Modic changes Sclerotic Sclerosis Disc degeneration Spondylosis Schmorl’s node Facet joint hypertrophy Spondylolisthesis Synovial cysts Congenital stenosis Acquired stenosis Ligamentum flavum thickening Fissures Multi-level disc bulging, and Annular tears When any of these appear in the radiology records, they could  indicate long-standing spine pathology.  Remember:  MRI imaging has made it possible for the radiologist to take a closer look at the structures within the spine; therefore, the records reveal a lot more about the condition of the spine, provided the reviewer knows the technical jargon. The radiologist will rarely ever use the word chronic.  Therefore, the reviewer has to be familiar with those words which are indicate a chronic condition.  Having a solid understanding of the terms used to separate chronic verses acute is invaluable when determining what radiological abnormalities are directly related to an alleged injury. Debra West is a Registered Nurse and Legal Nurse Consultant with MKC Medical Management, Inc. Contact Debra at or at...

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