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VEGAS INC C OV E R STO RY One in four Americans say it is OK to defraud insurers shutterstock.com FRAUD, From page 1 Flax, a civilian contractor at O'Callaghan Federal Hospital at Nellis Air Force Base, pocketed the cash she collected from the women, then billed Air Force insurers for the implants. Health care fraud investigators say the deceit is common. Fraudulent billings are a lucrative tactic for scammers. In 2009, when Flax was committing her scheme, health care fraud, including bogus Medicare claims and kickbacks for worthless treatments, reached upward of $175 billion. Today, the problem is even worse. During the first eight months of 2011, the Justice Department prosecuted 903 cases of health care fraud – more than for all of 2010. Because Nevada's population is so small, the number of local prosecutions is relatively low. Industry sources say there were fewer than 100 health care fraud cases here in 2012. Despite the low numbers, the percentage of successful prosecutions is high, mainly because the state's health insurance industry, law enforcement and prosecutors are organized and on the same page about the cases to pursue and the approaches to take. "One of the things Nevada has going for it is that it has a very active U.S. Attorney's Office that is concerned about health care issues," said Gary Auer, director of the Special Investigations Unit for health insurer Anthem Blue Cross. Prosecutors are smart to take the fraud seriously. Health insurers say they save $11 in costs for every dollar they 18 20130415_VI01_F.indd 18 spend fighting fraud. ••• Health care fraud comes in a variety of flavors. Most involve bogus claims, such as the Flax case. Others include physician overbilling, identity theft, staged traffic accidents, fake slip-andfall injuries and drug abuse. Many scammers justify their behavior by slamming insurance companies and their desire for profits. quality medical care. One in 10 doctors reported medical signs or symptoms a patient didn't really have to help the person secure coverage for treatment or services. Insurance investigators hunt for fraud. They use computer systems to detect unusual payment patterns and collect tips from whistleblowers. ••• Law enforcement officials, on the "We've got a huge, huge public health problem, and it's not just here in Clark County. This problem is, by far, one of the worst things we're facing as a country. If you look at it, there are safeguards in place, but obviously there appears to be some serious deficiencies in the way we're going about it." — Paul Rozario, assistant special agent for Nevada's Drug Enforcement Administration Often, there is a cavalier attitude about fraud and insurance companies, the Coalition Against Insurance Fraud reported. Accenture, a management consulting company, conducted a study that found one in four Americans believe it's acceptable to defraud insurers. One in 10 said it is acceptable to submit claims for personal injuries that never occurred, and two in five said they were unlikely to report someone who ripped off an insurer. Doctors aren't above sticking it to insurance companies, either. The Journal of the American Medical Association reported that almost one in three physicians said it is necessary to game the health care system to provide high- other hand, focus on prescription drug abuse. "We've got a huge, huge public health problem, and it's not just here in Clark County," said Paul Rozario, assistant special agent in charge of Nevada's Drug Enforcement Administration. "This problem is, by far, one of the worst things we're facing as a country. If you look at it, there are safeguards in place, but obviously there appears to be some serious deficiencies in the way we're going about it." Seven million people, or 2.7 percent of the U.S. population, used psychotherapeutic drugs nonmedically in 2010, according to the National Institute on Drug Abuse. About 5.1 million people abused painkillers, with one in 12 high school seniors using Vicodin and one in 20 using OxyContin. Nevada has one of the worst rates of nonmedical use of prescription pain relievers, according to the Substance Abuse and Mental Health Services Administration. "What we do is we investigate doctors and pharmacists who are involved with the illegal diversion of prescription drug medication," Rozario said. "When I talk about illegal diversion, I'm talking about the filling of prescriptions without any legitimate medical purposes." Leads come from whistleblowers and doctors concerned about dishonest colleagues. The DEA maintains a database of registered dispensing pharmacists, and the agency performs periodic audits. "We also work with state medical boards and pharmaceutical boards for potential leads to see if they have any concerns relative to anybody they feel is not in compliance with their policies and may not be in compliance with DEA regulations," Rozario said. "We do what we can do by holding doctors and pharmacists and people who work with them in their offices accountable if they are abusing the system. It's a very small minority, but that small minority can adversely affect not only what's going on in Clark County, but other parts of the country." ••• The third leg in Nevada's effort to combat medical fraud is prosecution. The Nevada Attorney General's insur- | 15 APRIL 2013 | 4/11/13 3:03:33 PM