Sept. 23 deadline looms for business compliance with HITECH Act on patient privacy

Organizations handling healthcare data have a month to comply with new security and privacy requirements under the Health Information Technology for Economic and Clinical Health (HITECH) Act.

After Sept. 23, all covered entities, including online storage vendors and cloud service providers, will be subject to new breach notification standards and limitations on how they can use and disclose PHI. They will also be required to ensure that their business associates and subcontractors are compliant with the privacy and security requirements of the Health Insurance Portability and Accountability Act (HIPAA). The HITECH Act amended portions of HIPAA by adding new security and privacy provisions on patient information.

In addition, covered entities will be required to have updated patient privacy notices in place that state the patient's rights over the data and how the data can be used and shared.

Unlike the original HIPAA privacy and security rules, which primarily applied to healthcare organizations and insurance companies, the new HIPAA Omnibus rules apply to business associates and their subcontractors. Under the omnibus rules, a business associate of a healthcare provider, such as a cloud service provider, is directly liable for protecting any patient data it handles, even if the vendor is just storing the data.

Business associates are also liable for ensuring that any subcontractor it hires, such as a document-shredding company, is similarly protecting PHI.

The new rules for safeguarding PHI create a complex liability chain, said Peter MacKoul, president of consulting firm HIPAA Solutions LC. A covered entity or a business associate could face stiff civil penalties for a breach by a subcontractor, regardless of how far down the chain the subcontractor might be, he said.

Under Omnibus HIPAA rules, covered entities and business associates are directly responsible for protecting against the use of PHI by employees, contract workers, trainees and even unpaid volunteers and interns, MacKoul noted.

The rules also give healthcare organizations and business associates less latitude to determine when to make a breach notification, he said.

Previously, a healthcare organization needed to notify individuals of a data breach only if there was a serious risk of financial or reputational harm. Under the new requirements, covered entities and business associates will be required to issue a breach notification in most cases, unless they can specifically show there is a "low probability" of the breached data being misused, MacKoul said.

Healthcare companies will be required to consider four specific factors, including the nature of the data that was breached and whether PHI was acquired or viewed only, to determine the seriousness of a breach. Importantly, breach notification requirements can be triggered even if an employee, contractor or unpaid volunteer uses PHI in an impermissible manner, he said.

Healthcare entities need to identify all their business associates, especially newly covered entities such as data storage companies, and ensure they have proper business associate agreements with them by Sept. 23, said William Maruca, a partner with Fox Rothschild LLP.

Healthcare companies also must have updated patient privacy notices in place by the deadline, Maruca said. The notice must specifically state that the covered entity is required to obtain the patient's authorization to use or sell his or her information for marketing or other purposes and to use or disclose psychotherapy notes, Maruca said. Privacy notices will also need to include a description of how an individual can revoke an authorization and explain their right to receive a notification in the event of a data breach, Maruca said.

"I think the readiness level varies considerably," Maruca noted. "Larger health systems and similar organizations with dedicated health privacy officers may be ahead of the curve, and some savvy smaller entities have been very proactive," he said. But "others are dragging their feet. I think it may take a high-profile enforcement ... to get the attention of the smaller players."

Deborah Peel, founder and chairman of the advocacy group Patient Privacy Rights , noted that while the changes are designed to improve patient privacy, several loopholes remain.

Despite the changes, most health data can still be sold, she said. There is also no chain of custody for health data despite the generally strong security and contract requirements for business associates and subcontractors, Peel said.

As a result there is no way for patients "to obtain a complete map or picture of who used your health information or why. Without a complete data map that tracks all flows of data, we have no idea about the harms and misuses, making it impossible to weigh the risks vs. benefits of using," health information technology systems, she noted.

http://www.computerworld.com/s/article/9241913/Sept._23_deadline_looms_for_business_compliance_with_HITECH_Act_on_patient_privacy

3 quality, coordination lessons from the Beacons

Being able to digitally submit clinical quality measures (CQMs) to Medicare is one of the big promises of health IT for physicians and providers — and it’s still coming, along with other administrative simplifications.

But digital CQMs have been put to good use on the ground by some of the 17 Beacon Communities, the Office of the National Coordinator for Health IT argues in an issue brief. As the ONC and the Centers for Medicare & Medicaid Services finalize novel eCQMs for Medicare, in the areas of clinical care, care coordination and outcomes, here are three lessons from the Beacons on using quality measurements.

1. Beyond billing.

One common complaint from some physicians has been that particularly older EHR software systems are mostly designed for documentation and billing, with analysis tools being limited and not very usable.

Nowadays, providers are increasingly able to put their EHRs to use measuring their patients’ trends and their clinical performance, which can help develop a culture of improvement — providers turning to their data to scrutinize their care quality.

Through the Crescent City Beacon Community, in New Orleans, 17 providers worked with payers, vendors and other partners to start standardizing digital clinical data, with the goal of using the local health information exchange as a source of clinical quality measures.

Before they can do that, the health data is being validated. Data accuracy is especially important in a city where thousands of patients’ paper-based medical histories were lost to the floods of Hurricane Katrina.

The community-wide HIE will eventually be put to use reporting quality measures, offering community dashboards, provider performance and Meaningful Use reports.

The HIE is also currently deploying a software offering the ability to track patients and coordinate their care management across settings.

2. Aligning CQMs with value-based payments.

Much as Farzad Mostashari, MD, has heralded the decline of fee-for-service (often Tweeting #FFSdemise), only a minority of the healthcare services rendered in the U.S. are currently reimbursed through some type of accountable care or valued-based contract.

Still, healthcare made accountable or measured for value is happening, such as in Indiana. Through the Central Indiana Beacon Community’s Quality Health First program, the Indiana Health Information Exchange offers analytics and patient summaries for docs — showing them, for instance, all patients due for preventative screenings — to help them develop intervention and management programs for patients with chronic diseases.

The program helps providers submit Meaningful Use compliance attestation reports, and lets payers access clinical data, beyond claims, to track provider performance and tailor reimbursement. As of January, 114 provider groups representing 2,252 primary care physicians and 1.4 million patients have participated in the program.

3. Building consensus among unaffiliated orgs.

Fee-for-service’s “misaligned incentives” resulted in a culture of health organizations often only reluctantly sharing patient data with unaffiliated providers, if not “hoarding” the data by default, and that’s resulted in poorly coordinated care for some patients being served by primary care doctors, specialists, hospitals and other providers. And that’s in addition to patients having to navigate healthcare finances from separate providers.

In Bangor, Maine, the small city where Stephen King lives, the Bangor Beacon Community in large part incentivized collaboration for the care of the region’s most vulnerable, with clinicians and care managers meeting to discuss disease management strategies, and robust HIE services performing the bulk of the data management.

The Beacon launched a care coordination project for patients with diabetes, congestive heart failure, COPD and/or asthma, among 124 primary care doctors from three large healthcare organizations, Eastern Maine Medical Center, St. Joseph Hospital, and Penobscot Community Health Care.

For those patients, hospital admissions decreased 42 percent, emergency room visits by 43 percent, and walk-in care visits decreased by 75 percent over the course of 2011 and 2012.

With the goal of tracking the quality of care particularly for diabetes, heart disease, COPD and asthma, the collaborative approved data definitions, revised operational terms, identified regional target goals, and created common EHR patient encounter forms and workflow processes. Powered by Maine HealthInfoNet, the statewide HIE, the providers use a data registry that’s automated with their EHRs and sends them patient summaries.

The Bangor Beacon was successful with multi-organization quality metrics, the ONC concluded, in part because the “third-party centralized disease registry fostered a simplified, less competitive environment for negotiating data sharing agreements.” It also meant independent checks of data integrity.

http://www.govhealthit.com/news/3-quality-coordination-lessons-beacons

Health care companies get new sustainability accounting standards

By Michael Kramer

Created 2013-08-26 05:00

The nation's top sustainability accounting nonprofit has issued new accounting standards for several health care subsectors, including biotechnology and pharmaceuticals.
The American National Standards Institute authorized the Sustainable Accounting Standards Board (SASB) to develop sustainability accounting standards to help publicly listed corporations report sustainability issues to investors and the public.
The SASB is in the process of setting sector-specific standards for the disclosure of environmental, social and governance (ESG) issues in SEC filings for 80 industries across 10 economic sectors. The new SASB provisional standards released this month are aimed at industries in the health care sector, including biotechnology, pharmaceuticals, medical equipment and supplies, health care delivery, health care distributors and managed care.
I think the standards, based on dozens of specific metrics, are well conceived as drafted thus far. Such information never has been standardized in a way that could properly inform investors, so the emergence of the SASB’s standards sets a high and uniform bar for how companies must share information. There is no doubt among sustainable investors that such information will relate directly to share value.

Product focus for biotech and pharmaceuticals standards
For the biotech and pharmaceuticals industries, companies must disclose ways they offer medicines to high-priority countries, recalls, unused product takebacks and safety issues, such as adverse side effects. Companies must discuss clinical trial safety protocols and any legal or regulatory fines or settlements therein. They must divulge how product prices compare to the Consumer Price Index. Fines or settlements for false advertising, corruption and poor manufacturing practices also must be revealed, while employee recruitment, retention and training programs must be elucidated. Product traceability, manufacturing energy and water use, and waste procedures also are measured.
Other sustainability topics for the biotech and pharmaceutical standards address supply chain management, consumer access, safety, employee relations, marketing, pricing, corruption, counterfeiting and natural resource and energy conservation.

Interesting health care delivery standards
I find the standards for health care delivery intriguing. They address quality of care issues, such as health care acquired infection rates, patient satisfaction, ratings on clinical process and outcome domains, and excessive serious reportable events.
These companies also must share their strategies for facilitating access for low-income patients, including including alternative pricing mechanisms, billing and pricing frameworks. Patient privacy procedures must meet a high standard. Employee turnover and talent recruitment and retention strategies also are assessed, as are incidents of fines and settlements for Medicare and Medicaid fraud. In the environmental arena, energy use and waste generation are evaluated, while companies must reveal strategies for how climate change risks may affect business operations.
Both the health care delivery and managed care subsectors must discuss access, privacy, transparency, fraud, employee relations, improved outcomes, plan literacy and performance, energy and waste efficiency, and climate change impacts on human health.

Managed care industry disclosure zeroes in on cost
Specific standards pertinent to managed care relate to cost and revenue schemes that enable access to care, claim denial rates, grievance rates, Medicare plan rating and employee retention rate.
Clarity in pricing and coverage is assessed, as is the privacy and security of customer data. Regarding medical care, enrollment in wellness programs and the coverage of preventive services is highly valued.

A good start
It is encouraging to see the breadth and depth of these accounting standards.
Considering the breadth of reporting systems, such as those from the Global Reporting Initiative and the International Integrated Reporting Council, the value of the SASB’s disclosure protocols will help investors to understand the material risks and opportunities of the companies they may own.

http://www.greenbiz.com/blog/2013/08/26health-care-companies-sustainability-accounting-standards

HHS settles with health plan in photocopier breach case

Under a settlement with the U.S. Department of Health and Human Services (HHS), Affinity Health Plan, Inc. will settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules for $1,215,780.  Affinity Health Plan is a not-for-profit managed care plan serving the New York metropolitan area.

Affinity filed a breach report with the HHS Office for Civil Rights (OCR) on April 15, 2010, as required by the Health Information Technology for Economic and Clinical Health, or HITECH Act. The HITECH Breach Notification Rule requires HIPAA-covered entities to notify HHS of a breach of unsecured protected health information.  Affinity indicated that it was informed by a representative of CBS Evening News that, as part of an investigatory report, CBS had purchased a photocopier previously leased by Affinity.  CBS informed Affinity that the copier that Affinity had used contained confidential medical information on the hard drive.

Affinity estimated that up to 344,579 individuals may have been affected by this breach. OCR’s investigation indicated that Affinity impermissibly disclosed the protected health information of these affected individuals when it returned multiple photocopiers to leasing agents without erasing the data contained on the copier hard drives.  In addition, the investigation revealed that Affinity failed to incorporate the electronic protected health information (ePHI) stored on photocopier hard drives in its analysis of risks and vulnerabilities as required by the Security Rule, and failed to implement policies and procedures when returning the photocopiers to its leasing agents. 

"This settlement illustrates an important reminder about equipment designed to retain electronic information: Make sure that all personal information is wiped from hardware before it’s recycled, thrown away or sent back to a leasing agent," said OCR Director Leon Rodriguez.  “HIPAA covered entities are required to undertake a careful risk analysis to understand the threats and vulnerabilities to individuals’ data, and have appropriate safeguards in place to protect this information.”

In addition to the $1,215,780 payment, the settlement includes a corrective action plan requiring Affinity to use its best efforts to retrieve all hard drives that were contained on photocopiers previously leased by the plan that remain in the possession of the leasing agent, and to take certain measures to safeguard all ePHI.

For more information on safeguarding sensitive data stored in the hard drives of digital copiers: http://business.ftc.gov/documents/bus43-copier-data-security. 

The National Institute of Standards and Technology has issued guidance on media sanitation: http://csrc.nist.gov/publications/drafts/800-88-rev1/sp800_88_r1_draft.pdf. 

OCR offers free training on compliance with the HIPAA Privacy and Security Rules for continuing medical education credit athttp://www.medscape.org/sites/advances/patients-rights.

The HHS Resolution Agreement and CAP can be found on the OCR website athttp://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/affinity-agreement.html

HHS settles with health plan in photocopier breach case

Informatics' helps doctors unlock medical mysteries in mounds of data

• Article by: DAN BROWNING , Star Tribune 
• Updated: August 3, 2013 - 10:15 PM

An emerging field brings together doctors, mathematicians, programmers and other professionals in an effort to grasp the complexities of the human body.

It’s hard to see the future of medicine through the scabs, blisters and scars that torment 7-year-old Charlie Knuth as he makes his way haltingly to a checkup at the U of M Amplatz Children’s Hospital.

But the boy from Appleton, Wis., is helping doctors perfect a pioneering intervention called gene editing, a procedure that could lend hope to thousands of people suffering from hundreds of diseases — including epidermolysis bullosa, the disorder that causes Charlie’s skin to shear off and his eyes to blister.

Charlie’s case also illustrates the power of an emerging field called “biomedical and health care informatics” that’s beginning to revolutionize every aspect of medicine, from laboratory research to clinical treatments.

The doctors and Ph.D.s helping Charlie — a team that includes scientists at the U, in Massachusetts and in Germany — couldn’t have done their work without mining a massive genomic database that enabled them to interpret millions of bits of data in the boy’s DNA, according to Dr. Jakub Tolar, director of the U’s Stem Cell Institute.

That, in turn, allowed them to cut out a single, defective gene and splice in a correction without damaging side effects.

The procedure, which they described in a recent issue of the journal Molecular Therapy, is part of a larger movement that has medical professionals collaborating with physicists, mathematicians, statisticians, social scientists and computer engineers in an effort to create and mine “Big Data” centers. Much as Google, Facebook and Amazon mine massive amounts of data to discern consumer preferences, these researchers are sifting huge quantities of medical data to diagnose, understand and cure diseases.

The U, Mayo Clinic and several Minnesota businesses are well-positioned to take advantage of the trend. Five years ago, the U launched a special graduate program in Biomedical Informatics and Computational Biology (BICB). Partners include its Twin Cities and Rochester campuses, the Hormel Institute, Mayo, IBM, the National Marrow Donor Program and a brain research center at theMinneapolis Veterans Medical Center. And three years ago the U received a $5.1 million federal grant specifically to train health professionals in informatics.

Turning data into wisdom

Biomedical informatics starts from a simple premise: The human body represents a databank of stunning depth and complexity.

By 2015, the average hospital will have nearly 450 terabytes of patient data — most of it in the form of large, complex images from CT scans, MRIs and similar imaging techniques, according toresearchers at IBM and Wayne State University.

Beyond that are myriad other digital streams that could be tapped, such as Facebook and Twitter posts, which have proved useful in epidemiological studies, or monitoring devices such as Microsoft Kinect, which is being studied to understand movement disorders such as Parkinson’s disease.

And the stock of digital data will roughly double in volume every two years, according to a recent study sponsored by EMC Corp., a Massachusetts data storage and computing company.

Yet only a small fraction of existing data has been analyzed, which creates a huge job growth opportunity.

“We go from data to information, to knowledge to wisdom,” Tolar said. “And unless we have a very systematic way of looking at the data, we will not only lose a lot of the information, but also, we will do harm, in my opinion.”

The Obama administration put up $200 million last year for an initiative to improve medical care and cut costs by mining the growing stores of health data. At the National Institutes of Health (NIH), a program called Big Data to Knowledge (BD2K), underwrites projects such as mapping every neuron connection in the brain and large-scale genome sequencing of cancerous tumors.

“The goal is to develop new tools to analyze, organize and standardize all this data, so that it is easy for scientists to share and access,” NIH director Dr. Francis Collins explained.

Connie Delaney, dean of the U’s School of Nursing in Minneapolis and acting director of the Institute for Health Informatics, says the application of data mining to health care represents “a fundamental paradigm shift” that affects every scientific discipline and requires unprecedented collaboration to tap the breadth of skills required.

Doctors meet mathematicians

The U’s new BICB graduate program has 50 students enrolled; more than half are health care professionals who’ve recognized the need to acquire data analysis skills, said Claudia Neuhauser, a distinguished mathematician who directs the program.

Massive data sets require new tools of analysis, like the predictive modeling that Amazon uses to recommend certain books to customers, she said.

Biologists, she said, should learn “enough of the quantitative tools that they can analyze the data in a meaningful way,” Neuhauser said. “The onus is on [us] to develop ways of teaching so that biologists can fruitfully use the tools.”

In the past, scientists started with a hypothesis, then collected and analyzed the data to test the question that they asked, Neuhauser said; now they wade into massive data sets they already have, looking for ways to optimize treatment.

Analyzing the 3 billion base pairs of four letters that make up the human genome may seem complicated enough, but even more challenging, she said, “is the whole imaging piece.” Digital images from scans and high-tech processes like X-ray crystallography require huge databanks. And they are difficult to link to other data types, Neuhauser said.

But electronic health records are already being analyzed to ensure that patient care is cost-effective, said Bonnie Westra, a former software company founder who coordinates the informatics specialty within the U’s Twin Cities nursing program.

One study of 500,000 patients proved that certified nurses “absolutely” make a difference in the quality of care for patients suffering from incontinence, pressure ulcers and surgical wounds, she said.

The same database is now being mined for ways to predict which patients are likely to be readmitted after being released from a hospital.

Charlie’s legacy

In Charlie Knuth’s case, Big Data helped unlock the genetic code so that researchers could use molecular scissors to precisely cut out a single letter in his faulty genome and replace it with the correct one. Mark J. Osborn, an assistant professor at the U’s Pediatric Blood and Marrow Transplant Center, was the lead author in a recent peer-reviewed article in the journal Molecular Therapy describing the procedure.

The result: For the first time, Charlie’s skin cells began producing the “Type VII collagen” fibers that act like Velcro to anchor the skin in place.

Tolar said his team used the “heavy guns” of biomedical informatics and an advanced German genomics databank to demonstrate that the procedure would meet federal clinical standards as effective and safe. He now plans to seek approval to try it in humans.

“What I’m engaging is the DNA repair system that’s already operational in the cell,” Tolar said. “I’m just offering it some tools to repair itself, and that’s why it’s efficacious, right? Because most elegant things come from nature.”

http://www.startribune.com/lifestyle/health/218242151.html?page=all&prepage=1&c=y#continue

Attitudes to technology must change to drive healthcare innovation

By: Information Daily Staff Writer
Published: Monday, August 19, 2013 - 13:30 GMTJump to Comments

Health services are now expected to deliver quality care with a shrinking budget. The digital 'channel shift' could be the answer, but attitudes to technology in the sector must change.

In an exclusive interview with the Information Daily, Sudhesh Kumar, Pro Dean Research of Warwick Medical School, reflects on the progress and problems of health services in adapting to new technologies and new methods of communication.

"I don't think digital technology is a problem. I think there's issues around the way we use it. For example, one of the challenges is that we don't adopt the best technologies fast enough. In my hospital, we don't even have WiFi access". It is clearly impossible to even begin instigating more complex systems before basic services such as wireless internet are introduced.  

Related

• Improving NHS operations through healthcare data integration (14 Aug, 2013)
• Digital communication key to empowering NHS patients and staff (12 Aug, 2013)
• Mind the gap: The NHS must rethink its approach to patient information (26 Jul, 2013)
• 81% health professionals are investing in new technology (24 Apr, 2013)
• NHS Future Forum Calls On Healthcare Professionals To Make Patient Care A Reality (11 Jan, 2012)
• NHS Data Sharing With Private Sector Would Boost Research Says Cameron But Privacy Campaigners Not Convinced (5 Dec, 2011)

"There are rather curious rules about sharing data. Between professionals there has been a lot of confusion in this country about what you're allowed to share, that actually acts as a barrier to sharing information.

"The patient does not seem to own the data.. which means that the patient can't pass the data on to different agencies that need it… Its very frustrating for the patients and wastes a lot of time for the professionals". 

The shift within the NHS to systems of interaction that take advantage of new technology is long overdue, and has only recently been accelerated by external political agendas which have required the NHS to make millions of pounds worth of cuts. The only way to do this without damaging key services is toimprove NHS operations. 

"I think remote healthcare has to be the way we go now. The reason is, for a long period of time now, we've had more and more people going to doctors for various things. Most of the time, I am sitting there when I have a patient in front of me, and thinking 'why did they come here?"

http://www.theinformationdaily.com/2013/08/19/attitudes-to-technology-must-change-to-drive-healthcare-innovation

Family Docs Ask Feds to Extend Stage 2 of Meaningful Use by a Year

The American Academy of Family Physicians is asking the federal government to start Stage 2 of the electronic health records program on time, but to extend the compliance timeframe by a year.

The association, in a letter to CMS Administrator Marilyn Tavenner and ONC leader Farzad Mostashari, M.D., is concerned that regulatory expectations of Stage 2 and its existing timeframe will outstrip the capacity of many EHR vendors and ambulatory family practices to comply. “Though we do not wish to impede the progress of early adopter physicians poised for MU Stage 2 on January 1, 2014, we do not wish to see other family physicians who have committed to health care transformation through the thoughtful application of health I.T. to abandon the MU journey due to factors beyond their control.”

AAFP’s letter explains how extending Stage 2 compliance by a year would set up three distinct cohorts of physicians complying with meaningful use in different ways:

“Cohort 1 would include those eligible professionals attesting to MU in 2014 as their first payment year. They would be expected to implement 2014 CEHRT (certified electronic health record technology) and complete a reporting period of one quarter under MU Stage 1 prior to January 1, 2015, to receive their 2014 payment. In 2015, these EPs would be expected to complete an additional two quarters of MU Stage 1 prior to January 1, 2016 to receive their 2015 payment.”

“Cohort 2 would include those EPs attesting to MU in 2014 as their second payment year. They would be expected to upgrade from 2011 CEHRT to 2014 CEHRT and complete a reporting period of one quarter under MU Stage 1 criteria prior to January 1, 2015, to receive their 2014 payment. In 2015, these EPs would be expected to advance to compliance with MU Stage 2 criteria and complete a one-quarter reporting period prior to January 1, 2016, to receive their 2015 payment.”

“Cohort 3 would include those eligible professionals attesting to MU in 2014 as their third or fourth payment year. They would be expected to upgrade from 2011 CEHRT to 2014 CEHRT, advance to compliance with MU Stage 2 criteria, and complete a reporting period of one quarter prior to January 1, 2016, to receive their 2014 payment. By completing any two quarters under MU Stage 2 criteria prior to January 1, 2016, they would receive both their 2014 and 2015 payments.”

The complete AAFP letter, including a graph visually demonstrating the three-prong proposal, is available here.

http://www.healthdatamanagement.com/news/ehr-electronic-health-records-meaningful-use-46488-1.html

Texas Uses Data Visualization to Combat Medicaid Fraud

by Christopher Nerney   |   August 15, 2013 5:43 pm   |   0 Comments

The Texas Office of Inspector General used the LYNXeon visualization tool to track connections among government payments, health care providers and Medicaid recipients. Image above is an illustration, courtesy of 21CT.

Pinning down how much taxpayer money is lost to Medicaid fraud is difficult simply because the successful frauds go undetected. But the U.S. Government Accountability Office estimated that $32.7 billion (or 10 percent) of state Medicaid payments made in 2007 were improper. Other estimates are much higher.

It’s no wonder why. A huge federal program such as Medicaid — which provides health and medical services funding to poor individuals and families — involves a byzantine network of care providers, medical institutions, pharmacies, drug manufacturers and patients spread across 50 states.

Consequently, there are a number of schemes used by providers and patients to defraud Medicaid. Among them are:

• Billing for services not rendered
• Double billing
• Billing for more hours than there are in a day
• Substituting generic drugs
• Billing for more expensive procedures than performed
• Kickbacks to nursing homes
• Personal expenses in nursing home Medicaid claims

“People who are committing fraud spend all day, every day thinking about it. They come up with new ideas, they come up with ideas about how to hide their tracks. That’s their job, it’s what they do,” says Jack Stick, deputy inspector general for enforcement for the State of Texas’s Office of the Inspector General (OIG). “But people whose job it is to fight fraud do it during a regular work day. So we’ve got to think faster than they do, think better than they do, and leverage technology.”

Related Stories

Oklahoma IT consolidation sets stage for analytics use cases.
Read the story »

Analytics, IT firms promote business benefits of federal data bill.
Read the story »

Philadelphia chief data officer seeks economic growth via open data.
Read the story »

National Hurricane Center predictive models improve forecasts.
Read the story »

The technology the Texas OIG has chosen to leverage in its battle against Medicaid fraudsters is LYNXeon, a data analysis and visualization software platform designed to collect, analyze and visualize data for investigative analytics and pattern detection.

LYNXeon is made by 21CT, an Austin, Texas-based company that began in 1999 as an incubator for the U.S. Department of Defense and intelligence communities. Customers of 21CT include the branches of the U.S. armed forces, the Department of Homeland Security, and several Fortune 1000 companies.

Stick says the Texas OIG, which currently has 90 investigators tracking down Medicaid fraud in a state with more than 26 million residents and one of the highest poverty rates in the country, began loading its billions of lines of data into LYNXeon last January.

“By March we were ready to go live with 10 percent or 11 percent of the total available data,” Stick says. “They identified $20 million in potential overpayments based on just that limited amount of data.”

Once LYNXeon flags possible Medicaid fraud, Texas OIG “goes in and lays hands on the cases to do the actual investigation,” Stick says.

The power of LYNXeon, which was launched in 2004, resides in its ability to turn huge amounts of data into visualizations that allow users to see patterns they otherwise may have overlooked. For an understaffed agency charged with enforcing compliance with a massive federal program, data visualization is an invaluable tool.

LYNXeon runs data through four stages, according to Kyle Flaherty vice president of marketing for 21CT.

“It starts with machine learning models and algorithm scoring,” he says. “This spits out a bunch of leads for investigators.”

From there LYNXeon filters data through targeted queries designed to get information about specific behaviors, such as unusual billing patterns or purchases.

Stages three and four involve visualizations, he says.

“We use link analysis to determine context between people, places and things,” Flaherty says. “By visualizing the connection paths, LYNXeon allows investigators to expand and pivot off this information and get to the root of how they’re perpetrating fraud.”

Finally, pattern and social networking analytics “can really arm a good investigator to find something he never could before,” he says.

Stick says this is especially true when you use a wide range of data.

“What we’re doing with LYNXeon is adding in Medicaid data, Medicare data, Dun & Bradstreet data,” he says. “So if we find that a provider bills for a lot of procedures, but Dun & Bradstreet  tells us that they never turn the electricity on, that’s a pretty good indicator that there’s waste, fraud and abuse going on.

“We also can look at the Medicaid payment data and put it into context,” Stick says. “We can compare that provider to his or her peers, we can look to see if they’re in a building that’s physically large enough to house what they’re doing.”

LYNXeon also gives Texas OIG the ability to investigate recipients of Medicaid and other benefit programs.

“We can see if your EBT (Electronic Benefit Transfer) card is active in Dallas one day, but you’re receiving Medicaid services in Houston on the same day,” Stick says. “And we can track retailers that are fraudulently buying electronic benefits for pennies on the dollar and then redeeming them for full value.”

Nearly six months since going live, Stick says LYNXeon has identified more than $180 million in potential Medicaid overpayments for Texas OIG to investigate.

“If only a fraction of what we’ve identified through LYNXeon proves to be waste, fraud and abuse, and we recover that money or at least avoid spending that money in the future, we will already have paid for LYNXeon,” says Stick. “It’s by far the best money I have ever spent in government.”

Contributing Editor Christopher Nerney (cnerney@nerney.net) is a freelance writer in upstate New York. Follow him on Twitter: @ChrisNerney.

- See more at: http://data-informed.com/texas-uses-data-visualization-to-combat-medicaid-fraud/#sthash.KLqzZIrw.dpuf

La. ranks #1 in recovered Medicaid fraud money

Baton Rouge, La. - State health officials said recent figures show Louisiana led the nation in recovered Medicaid fraud funds last year.

The Department of Health and Hospitals released details in a news release on Tuesday. DHH says the state Medicaid fraud unit recovered more than $124 million during the past fiscal year, according to the Centers for Medicare and Medicaid Services.

The numbers showed that represented nearly 2 percent of all spent Medicaid dollars in Louisiana. On average, states recover less than 0.6 percent of their respective Medicaid budgets.

DHH Secretary Kathy Kliebert credited the work done by their Program Integrity division, and the agency's improving relationship with the Attorney General's Office.

"We take fraud and abuse of the Medicaid system very seriously in Louisiana," Kliebert said.

Kliebert also said a number of improvements were being made in the division to help continue to combat Medicaid fraud, as well as detect and correct billing errors.

http://www.fox8live.com/story/23130347/la-ranks-1-in-recovered-medicaid-fraud-money

Medicare Fraud Horror: Cancer Doctor Indicted for Billing Unnecessary Chemo

Michigan oncologist Farid Fata allegedly squeezed profits out of patients by prescribing unneeded treatments and inventing diagnoses

Undergoing chemotherapy when you have cancer can be a terrible experience. Undergoing chemotherapy unnecessarily when you don’t have cancer is worse.

That’s what happened to some patients of a Detroit-area oncologist, according to federal investigators, who say the physician netted millions of dollars from Medicare by needlessly treating people for various ailments, including cancer. Indicted Wednesday on a charge of Medicare fraud, Dr. Farid Fata is being held in a Detroit jail on $9 million bond.

“We have been trained to trust doctors with our lives,” says Barbara McQuade, the U.S. Attorney for the Eastern District of Michigan, who is helping prosecute Fata. “When you see a case like this, it’s startling.”

The Fata case, which is being investigated and prosecuted under the direction of a task force run jointly by the federal departments of Justice and Health and Human Services, is highly unusual. Typical Medicare fraud cases involve health care providers billing the government for services that were never delivered. Some fraudulent providers buy Medicare ID numbers on the street. Others pad billings to increase profits or procure medications to sell illegally. Many are found out when federal investigators spot anomalies in their billings. But Fata appears to have been charged after whistleblowers approached federal authorities with information that he was potentially injuring patients just to up profits. McQuade, whose office has prosecuted numerous Medicare fraud cases in Detroit, says she’s seen lots of schemes but “nothing as egregious as this.”

(MORE: The Secretive Group Behind Medicare Reimbursements)

According to a criminal complaint filed on August 6 and based on an investigation by the FBI, Fata routinely prescribed chemotherapy and other drastic medical interventions for patients who were either healthy, or ill but in need of alternate treatments. He did so purely to increase his own income, according to prosecutors, who say Fata billed Medicare for some $150 million in services between August 2010 and July 2013, some of it fraudluently. The complaint, based on interviews with several nurse practitioners, medical assistants and an oncologist who worked for Fata, reads like a horror novel.

The oncologist told the FBI of one patient who received chemotherapy under Fata’s care, even though the patient was in remission. The oncologist advised the patient to get a second opinion and he or she never returned to see Fata. The oncologist also told the FBI that Fata ordered chemotherapy for all of his end-of-life patients, even if the treatment would not improve or extend their lives. The oncologist told the FBI, “no other physician would do this and would let the patient die in peace.” The oncologist also said Fata sometimes issued patients life-long prescriptions of drug treatment for low platelet conditions, without informing patients that surgery was a treatment alternative to years of drug therapy. The oncologist also told the FBI that many of Fata’s patients received intravenous immunoglobulin therapy even though they did not need it. A nurse practitioner who worked for Fata examined charts for 40 patients undergoing this treatment and found that 38 did not need it at all.

The criminal complaint also outlines accusations that Fata arranged for foreign doctors, who might have been unlicensed to practice medicine in the U.S., to treat patients in his multiple clinic locations. “Dr. Fata sees the patient only for 2-3 minutes. The patients frequently complain about it,” states the complaint. In even more egregious cases, investigators say Fata falsified cancer diagnoses in order to justify—and receive payment for—positron emission tomography (PET) scans, which include radiation. These diagnoses, say investigators, are “written in the chart purely to justify the fraudulent billing to the insurance company.”

(MORE: The Backstory Behind a Hospital Bill)

Incredibly, the complaint gets worse. Investigators said one patient fell and hit his head at one of Fata’s clinics. But before sending the patient to the hospital for treatment, Fata allegedly directed an employee to give the patient chemotherapy. “The patient later died from his head injury,” according to the complaint.

Fata’s lawyer, Christopher Andreoff, says the doctor has no prior criminal record and “is devastated” by the accusations.

“His entire medical practice and his treatment of patients has come to a complete standstill,” says Andreoff. “His liquid assets are frozen and he’s not going to be able to pay payroll.” The FBI investigation and indictment “came out of the dark like a bad thunderstorm,” he added.

According to the Detroit Free Press, Fata could face 10 years in prison and a $250,000 fine if convicted. McQuade says the investigation is ongoing. No trial date has been set, but Andreoff says he expects prosecutors to provide more information to Fata’s defense team, including the names of current and former Fata employees who spoke to the FBI.

Read more: http://nation.time.com/2013/08/15/medicare-fraud-horror-cancer-doctor-indicted-for-billing-unnecessary-chemo/#ixzz2c3XYCfHj

Contest Seeks Innovations To Benefit Aging Population

Ecumen and Mojo Minnesota have teamed up to launch an international contest that seeks innovative products and services to benefit the growing aging population.

by Rebecca Omastiak

August 12, 2013

Local organizations Ecumen and Mojo Minnesota are seeking both high- and low-tech solutions to benefit people as they grow older.

Ecumen—a Shoreview-based nonprofit senior housing and services provider—and Mojo Minnesota—a Minneapolis-based cooperative consisting of entrepreneurs, venture capitalists, angel investors, business advisors, and engineers—recently launched their inaugural AgePower Tech Search contest, inviting individuals, startups, and established companies to submit new products and services that are ready to be tested among the senior population.

The two partners said they are looking for functional prototypes that demonstrate a real-world purpose and are positioned for investor interest and commercial success.

“We’re not seeking ‘ideas’ or ‘concepts,’” Ecumen spokesman Eric Schubert told Twin Cities Business. “The submitter must be working to commercialize the technology within the next 12 months with the focus of having a broad, positive impact in life quality, profitability, job creation, and community engagement.”

Ernest Grumbles, co-founder of Mojo, told TCB that “this is not a traditional business plan contest.” Rather, he said, it’s an opportunity for innovators to “road test” their technologies.
 

After completing a screening process, Ecumen and Mojo plan to select roughly four finalists who will gain access to field-testing and feedback. Test environments include Ecumen’s in-home and clinical care settings, assisted living communities, and physical rehabilitation centers.

 

Mojo said it will lend its expertise to help finalists actualize their market potential.

In exchange for the resources Ecumen and Mojo offer, the partners receive a small equity stake (Grumbles said the working figure is 3 percent) in the finalists’ products or services.

“This search fits the sweet spots of both organizations in terms of innovation, collaboration, and helping move Minnesota forward,” Schubert said.

Since the contest opened in July, it has received 10 submissions from locations as diverse as Israel and Ireland. Schubert described one submission as a workplace collaboration tool intended to keep track of work flow and documentation among care givers; another submission outlines a community networking platform and search tool to make senior services easier to find, he said.

Products and services for the aging population represent a Minnesota market in which there is a lot of “low hanging fruit,” Grumbles said.

“There’s a whole system devoted to medical and life care in Minnesota,” he added, referencing institutions such as Mayo Clinic. “[The state] is nationally recognized for social support and old age life improvement.”

“The world’s only growing demographic is people 60-plus,” Schubert added. “It’s our country’s fastest-growing population cohort. And Minnesota has so many attributes to lead in this space.”

Using data from a 2012 United Nations report, Ecumen and Mojo said that approximately 900 million people in the world are over the age of 60 and by 2050, that number will have grown to 2.4 billion. Ecumen President and CEO Kathryn Roberts said that growth represents an opportunity to improve the aging population’s quality of life.

Schubert said the contest taps into a need for near-term care solutions for the aging population by linking human ingenuity with technology.

“Our desire is that AgePower helps locate, optimize, and launch products that link with human skill to make lives better and are commercially viable,” Schubert said. “It’s a vehicle for helping open the door to Minnesota as a global hub for innovation for longevity and wellness.”

The AgePower Tech Search contest is open to applicants until October 31. Interested candidates can apply here.

Ecumen, which recently celebrated its 150th anniversary, owns or manages 55 independent-living and assisted-living communities, as well as 17 health care centers. It operates in 35 cities in Minnesota, Idaho, Nebraska, North Dakota, Tennessee, and Wisconsin. It reported $138 million in 2012 revenue and employs 3,952—3,800 of whom work in Minnesota.

Last May, Twin Cities Business cited Ecumen as an example of a business that is successfully using mentorship programs. Click here to read the story.

Mojo Minnesota, which was founded in 2010, is a cooperative of 13 individuals that mentors entrepreneurs and garners federal and state support for local startups. 

Wisconsin's med tech community: Driving a brain gain in health care innovation

As home to some of the nation's leading medical imaging and technology companies, Wisconsin is a leader in health care technology, research and development. Ranging from small start-up companies to long-established manufacturers, the state's health care technology sector is developing products that are improving health care delivery and patient lives around the world.

Recently, some of the state's most forward-thinkers in the medical technology sector met with Lt. Gov. Rebecca Kleefisch to discuss the progress and challenges Wisconsin's medical technology community is experiencing. Lt. Gov. Kleefisch, as a colon cancer survivor, has a unique connection to the health care technology sector in Wisconsin and understands the importance of supporting public policies and partnerships that will protect the future of medical technology innovation in the state.

The tremendous amount of knowledge and talent across Wisconsin has helped establish the state as a leader in medical technology. Known as "brain gain" by both leaders in the State House and the health care sector, the value investment that education and medical research brings to the state's economy and job base resonates with government, industry and the public.

A few examples:

* Medical innovation and health care research are valuable drivers of Wisconsin's state's economy, contributing approximately 42,000 direct and indirect jobs, and nearly $9 billion to the state's economy.

* Data just released by the Medical Imaging and Technology Alliance named Wisconsin one of the top five states for medical imaging jobs nationwide.

* GE Healthcare alone generates more than $10.4 million in economic activity in-state, on average, every day, and helps support more than 21,000 jobs at GE businesses and at 1,100 supplier sites across Wisconsin.

At the same time, the challenges confronting health care systems are numerous, and identifying ways to improve health care outcomes and contain health care costs is no easy task. Medical innovation is vital to the development of products and processes that will strengthen our health care system. Bold technologies are in development that hold the promise of helping physicians diagnose Alzheimer's Disease, assess the effectiveness of cancer treatment, and increasingly shift the market to more precise diagnostics that will change the way disease is diagnosed and treatments are prescribed. Combined with the power of data analytics and predictive tools that will help health care providers improve efficiency, technology advancements can help save lives and reduce health care costs.

Continued investment in medical innovation and related education is critical to advancing health care and competitiveness. Wisconsin is a leading example of how the medical technology industry as a whole continues to work with state and federal lawmakers to advance policies that support continued medical innovation. On the federal level, bipartisan members of the Wisconsin Congressional delegation have been leaders on the Device Tax repeal and other health care technology issues, and they continue to fight for the interests of Wisconsin's medical device community. Within the state, a strong infrastructure of post-secondary public and private universities supports the quest for medical innovation and ensures a robust future pipeline of talented scientists, engineers, technologists and researchers.

Collaboration across Wisconsin's medical technology industry, state and federal lawmakers and academic institutions ensures that states like Wisconsin can help lead the way to the health care solutions of tomorrow and that the health care industry can transform from its current orientation of focusing on "sick care" to delivering better health care to more people more efficiently.

Mike Harsh is the chief technology officer of GE Healthcare.

http://www.biztimes.com/article/20130808/BLOGS/130809826/0/people_blog