Investigating Health Care Fraud
Investigations relating to health care fraud activity are reportedly at an all time high, and will continue to flourish with the advent of new working groups, task forces and other fraud-fighting activity that existence depends on the development and investigation of health care fraud cases. Simply put, the investigation of health care fraud consists of proving that the provider engaged in an intentional deception or misrepresentation (of material fact) that resulted, or could have resulted, in an unauthorized payment. Some key facts related to health care fraud investigations:Complaint Driven: Private, local, state and/or federal agencies are actively involved in the identification and investigation of health care fraud and abuse, which, for the most part, are initiated by complaints received from patients, insurers and others on a health care provider or entity.Complaint Evaluation: The investigative process starts by the investigator evaluating the information in the complaint to determine if it represents actual misconduct, and then to identify what specific laws, rules, and/or regulations may have been violated. Critical areas to be addressed may include:oDOCUMENTATION-was the services documented as medically necessary, and completely and accurately documented in the patient’s health care record?oREGULATORY LAWS & RULES-were the services rendered consistent with the administrative law for the State, including scope of practice, training, supervision and delegation? Additionally, were the services, or the manner in which they were rendered, in violation of prohibited conduct?oTHIRD PARTY PAYER RULES-were the services rendered consistent with the rules set by the involved third party payer, including those relevant to limitation of services rendered, and those limiting the service provider?oCODING-were the proper ICD-9 and CPT-4 codes used to identify the condition (s) being treated and the services rendered when seeking reimbursement?Investigative Plan: The investigator will identify potential witnesses to interview, other needed information, such as patient and insurance claim files that may possess evidence of the misconduct. The successful investigation will result in the collection identify and collect all relevant evidence that would indicate the laws, rules and/or regulations governing health care have been violated, and to identify storytellers who will be able to testify on matters relevant to the identified misconduct. The patient file is the crime scene when investigating health care fraud & abuse.MAJOR TRENDS IN HEALTH CARE FRAUDProblem (Multidiscipline Practices): Some multidiscipline practices of medical doctors, chiropractors, and other providers working together in one practice entity are formed by some chiropractors as a means to circumvent managed care and other third party payer limitations on reimbursement of chiropractic services. At times, when necessary, multiple corporations are created to allow the chiropractor to employ medical doctors and to maintain control over all revenues of the multidiscipline practice. The services rendered by the chiropractor in cases where there is little or no chiropractic coverage are billed to the third party payer under the license and name of the medical doctor, purportedly following “Incident-to” billing principles after the medical doctor evaluated the patient and referred them for care with the chiropractor. Is the chiropractor billing for their services rendered under the license of a medical doctor?Problem (Mobile Labs): Some external companies, or mobile labs, market their electro-diagnostic testing services extensively to health care providers as a means to increase patient retention and increase revenues. The mobile lab provides on-site electro-diagnostic testing on the provider’s patients with their equipment and by their technician. The provider pays the lab a rental fee for the equipment and technician, and agrees to provide a minimum number of patients for testing during one day. The lab bills the third party payer for only the reading of the tests, or the professional component, and the provider bills for administering the tests, or the technical component, because they rented the equipment/technician and supervised its administration. Further, the lab will provide the provider with the CPT codes and amounts that should be reported and billed for the technical portion of the test. The provider, claiming to have supervised the administration of the diagnostic test, may not have the requisite training and skill on the test. Often, the total amount billed (both professional and technical) for the tests will far exceed the RVU (Relative Value Unit) set for these tests. The client provider usually will have no actual knowledge on what the labs will bill to the third party payer. What service did the provider perform to bill for the technical portion?Problem (Rehab): Some providers implement (active) rehabilitation care into their health care practices by having their unlicensed staff administer therapeutic procedures to patients that are defined as one-on-one with the patient by a licensed provider, and are reported in 15-minute increments. Documentation of medical necessity of therapeutic procedures may not be properly established in the patient’s clinical record as part of a treatment plan. Documentation of procedures in file, even when directly provided by licensed provider, may not be properly documented to account for the time component of the service, i.e., Start & End time, which includes pre-intra-post service time. Is the provider’s unlicensed staff rendering the rehab services to the patients of the practice? What does the patient’s health care record show? Do they support the need and accuracy of the billings?Problem (Billing): Various insurance companies have limitations on what health care conditions and services they will reimburse providers for. Some providers provide their patients with health care services that are not reimbursable by the involved managed care organization or third party payer, but report and bill for these services via use of ICD-9 and CPT-4 codes that are reimbursable. Some providers provide their patients with various health care services based solely on the premise that the involved managed care organization or third party payer will reimburse for those services.Problem (Solicitation): A number of providers market “free” services, such as consults, exams and x-rays to attract new patients that may not be established as medically necessary, or will later be billed to a third party payer. A number of providers’ market “free” services, such as therapeutic massage, as a means to attract new patients to the health care practice, which later may become a part of the patient’s billed care. A number of providers inform marketed individuals when converting them to patients that they will not be responsible for what the insurance company does not pay. For the health care provider what is a consult? Isn’t it a history? Was the promised free service, or a portion of it, later billed? Is it possible to give away a therapeutic massage without first examining the patient to establish need?
8 Questions to Ask Your Home Health Care Agency Or Nurse
If you are in the process of finding a home care services agency or if you are considering hiring a home care nursing aide or a home health care physical therapist or occupational therapist, it is critical to find out their qualifications.We assembled a list of 8 questions you can ask the home care agency to ensure that you are choosing the right provider for your needs.1) What is the background of the home care company & how long have they been in business?You want to find a reputable in home nursing agency that has been in business for a number of years and has a successful track record. Most newer home nursing care agencies haven’t been around long enough to build a proven track record or a list of red flags.So, it’s important to find out as much information about the company as possible. You can do this by finding information on who owns the company and what role the ownership plays in the type and levels of service.2) What are the home nursing care agencies qualifications, certifications, experience and training of their home care aides and nurses?It’s extremely important to find out about the credentials of the home health aides and nurses that the home care company sends to your home.Make sure their home health aides and nurses are certified and have received adequate training.3) How does the home nursing care agency monitor care and can the family provide feedback?Find out if there are any quality assurance measures in place. Many home health care agencies periodically visit the home of the client or make regular calls to gather client feedback.If this is not the case, find out how a family member can provide feedback on the quality of care or who they may contact in the home care agency to have any questions answered.4) Are there any home visits or assessments that take place prior to home health care services beginning?Find out if there are any options available that allow the family members, client and the home care agency representative to meet prior to the start of services. Most reputable home nursing care agencies offer free consultations.5) Does the agency have a current operating license in their respective state or city?It is important to find out if the home health care agency has a current and valid license to operate in their respective city or state. This often overlooked aspect is the most important factor in choosing a home health care agency.6) How does the home nursing care company work with your doctor in developing a plan of care?Most agencies work directly with your doctor in planning for your care, especially if the client requires care that is beyond the scope of activities related to activities of daily living.7) Can the home care company provide references or testimonials?Most reputable home health care companies can provide references from doctors, nurses, social workers and even clients if requested. They may even have a page on their website that is dedicated to providing this type of information to potential clients.8) What happens if a home health aide or nurse is absent from the agency on a particular day?If the home health care provider is required to take a day off for illness or another emergency, what type of protocol is put in place by the home health care company to cover the absence?There are usually plans put in place to ensure that the client receives that continuity of care in the event of an absence by their home care provider or nurse.
What are anti-ligature blinds?
Anti-ligature blinds are becoming increasingly popular in a range of different settings. The way these blinds differ from traditional blinds is that they are designed to prevent suicide by hanging.
Initially, uptake for this type of blind was largely restricted to high-risk environments such as psychiatric hospitals and prisons, where suicide is common. In mental health environments and detention centres, suicide via hanging is common and preventative measures must be implemented. A huge range of objects could be used to create a ligature point, meaning anti-ligature systems are highly important.
Over the years, anti-ligature blinds have been supplied to hospitals, schools, student accommodation and even hotels.
How do they work?
There are a range of different systems on the market, but the most reliable could well be the magnetic anti-ligature system. YewdaleKestrel® products utilise load release magnets which separate when a downward force is exerted on the product. This means that the product falls to the ground safely and prevents suicide via hanging.
The magnetic systems used in Yewdale’s products are highly reliable because magnets don’t lose their strength for hundreds of years, guaranteeing a lifetime of lifesaving functionality.
Anti-ligature blinds usually have a magnetic connection point above the blind’s barrel. The blind is easy to reconnect to the magnetic bracket after it has fallen to the floor.
If you are considering an anti-ligature blind, Yewdale is a highly recommended company. Based in the UK, Yewdale produce a wide range of anti-ligature products, commercial blinds, and healthcare products including hospital cubicle tracks and medical curtains.
Yewdale produce other anti-ligature products too including a soft, lightweight en-suite door and other accessories such as soap dispensers, toilet roll holder, shelves and artwork. You can see the full range on the website using the link below.
Complete weight loss strategy
For those who want to lose weight
Research on the causes of obesity, knowledge about weight loss, and various diets for weight loss are updated every year. However, with the update of knowledge and the release of diet pills one after another, the obesity rate continues to rise every year, and there is no sign of wanting to decline. I used to be very, very fat, and I am also a person who is prone to obesity.
So I understand the voices of fat people, I really want to lose weight, but I tried many ways to lose weight at that time without success.
I have tried the common boiled meals on the market, eating less and moving more, but it was not until I tried other diets that I managed to lose weight. After I lost weight, I began to study the essence and method of losing weight, and wrote him in this weight loss strategy article, hoping to help you.
A few key myths about losing weight
The weight loss myth of eating less and moving more
The phrase “eat less and move more” is actually true, but most people do it wrong. Many people think that they should eat less of everything, so they limit their calories to a very low level, and it feels a bit like eating an ultra-low-calorie fairy meal. Then, for the hyperactive part, the first thing that everyone thinks of is aerobic exercise such as running, cycling, etc., but in fact, this is a very short-term and easy way to regain weight, mainly because eating too little is an easy way to lose weight. The reason for the loss of muscle mass, coupled with the fact that aerobic training is not helpful for muscle mass growth, causes the metabolism to drop too much.
Maybe you can lose 5 kilograms in this way, but if your metabolism declines, you will easily regain the weight. And it’s all the fat that gets back up, not the muscle you lose that makes you look fatter than before. This is what we call the yo-yo effect, lose weight, get fat back, get fatter than before, lose weight, get back on Fat, get fatter than before.
Stop taking diet pills and meal replacements
At this time, you may start to seek other ways, eat weight loss meal replacements, taking diet pills, and so on. But believe me, most diet pills will inevitably hurt the body, especially the gastrointestinal tract. You may actually lose weight in the moment, but when your gastrointestinal tract is damaged, you will be fatter than before.
The key to understanding how to lose weight
You must have thought, why some people will not gain weight no matter what they eat, while some people will gain a kilogram the next day after eating a little bread? What is the cause of obesity? This is not a simple answer that can be solved!
You can see the link to the picture below, mainly talking about the influencing factors of obesity, which are very, very complicated.
Image source: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-res.pdf
In the middle of this picture is the heat balance
So we can know that calorie balance is very important
But this article doesn’t keep preaching that calorie balance is the key to losing weight like other sites
If you don’t know what calorie balance is, you can probably imagine that our body has calorie consumption (exercise, thermogenesis, basal metabolism), and calorie intake (eating).
When calorie consumption exceeds calorie intake, the weight will drop, so the truth of weight loss is to eat less and move more, very simple. In the short term, it is really possible to simply achieve weight loss by eating less and moving more, but simplicity is not simple, because the operation of the body is very complicated. Many people think that they can control their calorie consumption, that they can achieve a lot of calorie expenditure by running all the time, and that eating fairy meals (low-calorie meals) can reduce calorie intake and then easily lose it.
However, according to research, 90% of people who use calorie control, eat less and move more to lose weight will fail or regain the weight.
Because eating less and moving more for too long, metabolism will easily drop, hormones will easily become imbalanced, and muscle mass will easily be lost. Even if you lose 10 kilograms, you will easily regain weight.
When losing weight, the body is like a factory
For me, the key to long-term weight loss and maintaining good posture is the environment in the body, such as hormones, the level of inflammation in the body, and the gastrointestinal system.
Think of the body as a factory
-Your hormones are the managers and workers of factory operations
-Inflamed condition is how good factory machinery and hardware are
-Calorie intake is wages for factories as well as fuel
If the manager of this factory is an idiot, or if the hardware in your factory is completely rotten, then no matter how it works, it will create a pile of waste. Just as our hormones are already out of balance and the level of inflammation in the body is very high, no matter how much you eat, if you don’t solve the existing problems, it will easily accumulate into fat. It may be easier to understand with a few examples.
Hormones vs Weight Loss
This study looked at the effects of sleep and weight loss
Research source: https://www.ncbi.nlm.nih.gov/pubmed/20921542
Both groups of humans were calorie-restricted, but one group slept 5.5 hours a night and the other 8.5 hours. Both groups lost weight, but the group that slept less lost 55 percent less body fat and 65 percent more muscle mass than the group that slept more. It is equivalent to losing weight, but most of the loss is muscle mass, which reduces metabolism and makes it easy to regain weight later.
There is such a big difference mainly because poor sleep has a negative impact. The imbalance of the secretion of these things will easily increase fat and reduce muscle.
This next study looks at the effect of insulin sensitivity on body composition!
Research source: https://www.ncbi.nlm.nih.gov/pubmed/19471290
Basically, many chronic metabolic diseases, obesity, and poor muscle-building effects are closely related to low insulin sensitivity. Insulin is an anti-catabolic hormone whose main function is to store nutrients in cells. For example, after heavy training, our muscles will be more sensitive to insulin, and the nutrients we eat will be more easily absorbed into the muscles. When insulin sensitivity is low, the nutrients we eat are more likely to be stored as fat rather than absorbed into muscles.
We can simply say that the nutrients in the food eaten by people who are insulin insensitive are more likely to be stored as fat, and the relative fat mass will be much higher than the muscle mass.
To put it simply, the key to losing weight is actually to improve hormones, improve inflammation in the body, and add an appropriate calorie deficit. It is not difficult to achieve a calorie deficit. What is more difficult is how to choose the type of food that suits your body to improve hormones and achieve a long-term good body.
If you only pursue short-term weight loss and rely on a lot of calorie deficits to achieve the effect of weight loss, and then the hormones are still the same after the loss, then I can guarantee that you will gain weight very easily.
With so many ways to eat on the internet, which diet should I try?
When talking about losing weight in Taiwan 30 years ago, everyone would definitely want to use boiled meals
When it came to losing weight five years ago, everyone might think of using a low-sugar diet. When it came to losing weight in the past two or three years, everyone might directly think of the ketogenic diet.
I lost 30kg in 3 months on a low-sugar diet myself for the first time, so I used to believe that a low-sugar diet was the best way to lose weight
But after my long-term understanding of weight loss-related research, genetic cognition, and observation of students, there is no diet that is most suitable for everyone! Although it is said that high-carbohydrate foods will most stimulate insulin secretion, which in turn promotes the storage of nutrients into fat, some people are naturally good at metabolizing carbohydrates, so they can still be healthy and strong after eating high-carbohydrate throughout their lives.
For example, this study compared the responses of people with high and low insulin sensitivity to high- and low-carb diets.
Research source: https://onlinelibrary.wiley.com/doi/full/10.1038/oby.2005.79
The study concluded:
-For people with high insulin sensitivity, eating high-carb and low-fat to lose weight is very helpful
-However, people who are insulin insensitive use a high-carb low-fat diet to lose fat, but the weight loss effect is not so good.
But on the contrary, studies have also shown that people with low insulin sensitivity have a very good weight loss effect on a low-carb high-fat diet, which shows that improving insulin is very important for weight loss, and it also shows that people with insulin insensitivity are more suitable
Lose weight with a high-carb diet.
So if you have been obese for a long time, you know that you eat carbohydrates easily, or you know that you have diabetes in your family and want to lose fat, then I would suggest that you can start by reducing carbohydrates, which is what we call low carb diet!
The Negative Impact of E-Levy on Mobile Banking.
DEFINITION OF TERMS
Mobile Banking is a service provided by a bank or other financial institution that allows its customers to conduct financial transactions remotely using a mobile device such as a smartphone or tablet.
Electronic Transaction Levy or “E-Levy” is a tax applied on transactions made on electronic or digital platforms.
ADVANTAGES OF MOBILE BANKING
Mobile banking offers numerous benefits such as ease of transaction, convenience, time-saving, managing your finances, and budgeting. Some advantages of Mobile Banking in remote areas include:
Financial Inclusion — mobile banking offers convenient and easy banking services to people in remote areas. Thus, it allows banking on the go and offers all benefits of a banking system to rural areas without the presence of a financial institution.
Accessing the bank 24/7 — Mobile banking provides ubiquitous banking services without the need to visit the bank to have access to services. This offers time to benefit and ease of transacting at a distance.
Cost-benefit — Mobile banking saves the banks the cost of building physical infrastructures (branches) and maintaining branches and staff. Also, reduced costs on the customer side since the burden of visiting the bank for services is eliminated.
Improving resilience in the face of poverty — Mobile money acts as both a savings vehicle and a means of transferring funds during times of economic or environmental shocks.
Strengthening the formal economy — For many micro, small, and medium enterprises (MSMEs), opening a mobile money account can facilitate access to formal financial services. Mobile money is well placed to address the issue of informality that blights many developing economies and hampers domestic resource mobilization efforts. Mobile Money enables ease of transacting, thus increasing business profits for MSMEs.
Facilitating economic growth — Mobile money has been shown to contribute to economic growth by increasing both productivity and per capita incomes
DISADVANTAGES OF E-LEVY ON MOBILE BANKING
The design of mobile money taxation policy appears to be the antithesis of a well-designed tax system. The disadvantages include:
Inequity — Mobile money taxes as currently structured to create inequity in the tax system. As the tax is mostly borne by the poor and users of the services are subject to additional taxation (unlike bank or cash transactions), the principles of both horizontal and vertical equity in the tax system are contravened.
Uncertainty -. Uncertainty and lack of transparency over taxation systems can have a direct impact on the operations of the tax authority, increasing enforcement costs, as well as discouraging investment.
Inconvenience — The administration of mobile money transaction taxes creates an inconvenience for MMPs who must calculate and collect the tax on the revenue authority’s behalf. There is an additional inconvenience for users of the service for whom remote digital transactions become more expensive or out of reach if they revert back to cash.
Inefficiency — Badly designed mobile money taxes have been shown to have a distortionary impact on demand for mobile money services. This in turn has had negative impacts on overall tax takes, as well as impacting the attainment of national economic and development goals.
EFFECT OF MOBILE BANKING — CASE STUDIES
The decision to impose taxes on mobile bank transactions will trigger so many problems.
Ghana — According to The Fourth Estate Ghana; Although the government projects a 24% decline in transactions when the levy is finally implemented, preliminary findings published by the bank of Ghana indicate the value of mobile money transactions had dropped by 3.2 billion in December 2021, less than 2 months after the proposal to introduce E-levy.
Uganda — An e-levy of 1% introduced in 2018 has led to an overall drop in the person-to-person transaction by more than 50%, and a 24% drop in industry transactions within the same year the tax was introduced according to a report by Global system for mobile communication (GSMA).
Congo — An e-levy of 1% was introduced in 2019. The government had to reverse the tax on cash outs only due to negative results of the levy on Mobile money users such as a decline in mobile money agents (unemployment) and high-value withdrawals by people.
Other countries include Benin (5%) and Cameroun (0.2%). In all these countries, the e-levy has imposed a negative effect on the economy and people. If we want to ensure the financial inclusion of people in rural areas, we need to ensure that we encourage mobile banking by withdrawing the e-levy tax.
Reference:
https://thefourthestategh.com/2022/03/16/e-levy-this-is-what-happened-when-other-african-countries-passed-it/
Purohit, S., & Arora, R. (2021). The benefits and challenges of mobile banking at the Bottom of the pyramid. Journal of Contemporary Issues in Business and Government Vol, 27(1).
Charles G. Kpan, Jr. is an Information Technologist with over 5 years of experience in the provision of Information Technology Services and an emphasis on Web Development and Visual Branding. He’s the managing Director of CYGEC IT SOLUTIONS INC. and holds a bachelor’s Degree in Information Technology from Blue Crest University, Liberia.