Sunday, March 1, 2009

Medicare And Medi-Cal Providers: What To Do About "Professional Patients" (PR-49)

One of the issues that we see in our practice is that physicians and health care providers who provide honest goods and services to Medicare and Medi-Cal beneficiaries are sometimes affected adversely by what is known as “professional patients.” These are patients who engage in fraud by receiving money for medically unnecessary services, products or medication or who simply sell their Medicare or Medi-Cal number.

Here is an example of what happens taken from an actual case with the patient’s name being changed. Patients like 81-year-old Anna Tinkarian (not her real name) who does not speak English made $125 every three months for about eight years. She had been approached by a patient broker or marketer who paid her and her neighbors money to get unnecessary medical services. Although she did not have any respiratory illness she went for unnecessary medical visits, and accepted several related medications, including oxygen, which she never used and threw away. There are some professional patients (like HIV patients) who can make $100 - $200 per visit.

At the same time, however, Anna had some actual health issues such as diabetes and wanted to see her longtime “real” doctor, Dr. Jinkarian, a Board Certified Internist, who had no idea that Anna was receiving all these other medical treatments and has no way of seeing any report detailing all her medical services. Dr. Jinkarian provides and bills for services and the claims are denied on the ground of PR-49. A PR-49 is what is known as an “overutilized beneficiary.”

In addition, just by having treated Anna, Dr. Jinkarian also becomes suspected of being a provider who is paying a marketer for Anna to come to him even though he has never done so. It does not help Dr. Jinkarian that he is from the same ethnic group as Anna and speaks her language. In order to collect on the claim, Dr. Jinkarian will have to file an appeal. Moreover, what should he do if Anna wants to come to him for additional medical treatment knowing that the claims will be denied because she has been designated a PR-49?

Dr. Jinkarian received his college and medical school education at fine schools in the U.S., did a prestigious residency and fellowship and decided to return to his community and give them access to an excellent provider. Instead, Dr. Jinkarian gets targeted as being part of the "fraud" in the health care system because some of his low-income patients have supplemented their income by getting payments for unnecessary treatments.

Authorities say there are thousands of professional patients in California and they play a large role in the fraud overwhelming the national Medicare and state Medi-Cal/Medicaid systems. Medicaid and Medi-Cal get involved since they provide supplemental benefits for those who are poor in addition to being elderly.

While authorities are successfully cracking down on real fraud by clinic owners and others, they disagree over whether prosecutors should go after the patients who get the phony treatments in these clinics.

In Miami and Los Angeles, government officials appear to have made a decision not to spend any of their resources on prosecuting patients. Perhaps they do not want a fraud trial where there are elderly sympathetic patients who are supplementing their social security with payments from marketers or patient brokers. Instead, the government focuses on proceeding against he providers and licensed physicians.

From 20 years of working in health care, we see that unless patients are disciplined, educated, face the loss of benefits and perhaps prosecution -- there will be little long-term impact on health care fraud. In addition, the government requires Medicare and Medi-Cal providers to not turn away patients. Honest providers are placed in an impossible situation. There are no lists of the PR-49 patients, their benefits are not taken away and providers are expected to provide them services. But if services are provided, it is the providers who are penalized and are treated as if it is they who are engaging in fraud. Thus, providers are expected to "police" the fraud by patients even when they cannot determine what services patients have received in the past.

Medical providers need to construct a compliance plan to address the fraud by patients. If a medical provider serves low-income, ethnic communities -- there is a higher risk of providing services to professional patients. The medical providers need to coordinate and be proactive with the government in how to handle these PR-49 patients or "overutilized beneficiaries." It is not enough for a provider to know that he or she is not paying marketing or kickbacks -- since their practice or business can be jeopardized by providing services to these patients.

We have seen "beneficiary detail reports" on patients that showed the patients going to their "real doctor" every several months for the serious medical conditions and then going to a different provider each month with a different complaint or diagnosis and then being referred to a pharmacy, lab, DME for that month. It makes it hard for the honest provider to separate itself from the web of fraud.

The state and federal governments should have an interest in doing something about this serious problem. They should be pragmatic about this and coordinate with medical associations and provider groups. These patients are often elderly and sick, will end up in hospitals and cost the government money for both medically necessary treatment and unnecessary. There needs to be an education process so that patients learn that this fraud is creating huge problems for everyone. While it may not be legal to deny benefits -- there will need to be some deterrance in order to stop the professional patients from participating in health care fraud. In the meantime, providers need to understand the fraud and work on protecting themselves.

Any questions or comments should be directed to: or call at 213-233-2260. Tracy Green is a principal at Green and Associates. The firm focuses its practice on the representation of professionals, particularly health care professionals including individual physicians, corporate providers and group practices.


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