Current statistics state that as many as 65 million Americans have high blood pressure (hypertension). The current main stay for treating hypertension is the use of medications. The most common types of medications used include diuretics, ACE inhibitors, and beta blockers. Though these medications can be helpful in the reduction of blood pressure, their long term use can cause a disruption of the vitamin and mineral balance in the body. Research is now showing that a disruption of certain vitamins and minerals can lead to elevations in blood pressure or an increased risk for cardiovascular diseases.
Below is a list of vitamins and minerals which have been shown to be depleted by blood pressure lowering medications and their potential effects of deficiency:
Calcium, Magnesium, and Potassium:
Recent research reveals that low levels of calcium, magnesium, and potassium can lead to elevations in blood pressure. In addition, magnesium deficiency is a contributing factor to elevations in cholesterol.
Zinc:
Zinc deficiencies have been shown to lower an individual’s antioxidant status. Low antioxidant levels have been associated with a higher risk for cardiovascular disease.
Coenzyme Q10:
Low levels of coenzyme Q10 have been linked to both high blood pressure as well as congestive heart failure. In addition, CoQ10 is a powerful antioxidant.
Folate & Vitamin B6:
These essential B-vitamins reduce the risk of heart disease by converting the toxic chemical homocysteine into harmless byproducts. Elevated homocysteine levels in the blood are as great a risk factor for heart disease as having high cholesterol.
Vitamin B1:
A deficiency of vitamin B1 can cause congestive heart failure as well as muscle soreness, and exercise intolerance. Exercise intolerance could potentially inhibit a person's ability to exercise. This in turn could lead to sedentary activity. Lack of adequate exercise is also a risk factor for heart disease, high blood pressure, and high cholesterol.
Vitamin C:
Vitamin C is a powerful antioxidant and is vital to healthy collagen production (blood vessel linings). Vitamin C deficiency has been related to elevated cholesterol levels and is necessary to maintain adrenal function through the production of hormones such as corticosteroid and aldosterone.
In summary, there are a number of published scientific studies that illustrate the effects of blood pressure lowering medications on nutritional status in humans. Based on these studies and the functions of the effected nutrients in the body we can logically conclude that taking blood pressure medications over long periods of time may actually increase the risk for heart disease, or at the very least, reduce the benefit from the medication. Because supplementation with these nutrients is safe and cost effective, it would seem prudent for physicians to monitor these nutrient levels with appropriate lab tests and to administer appropriate doses of these vitamins and minerals when deficiencies are identified.
If you are taking a blood pressure lowering medication and would like to learn more about how it may affect your nutritional health Visit: www.essential-nutrients.net/high-blood-pressure.htm
Dr. Peter Osborne, D.C., D.A.C.B.N. is the clinical director of Town Center Wellness in Sugar Land, TX. His practice focuses on integrative holistic care to include chiropractic, decompression, lifestyle coaching, as well as treating complex medical problems by identifying and correcting nutritional deficiencies through the use of specialized laboratory testing. He is a professor of nutrition for Houston Community College’s nursing programs. He has designed several formulations for different supplement companies including The “Ath-Elite” Protocol, a product customized for professional athletes. He is a member of the ACA Council on Nutrition, the American Association for Health Freedom, a Diplomate with the American Clinical Board of Nutrition, and a co-founder of Nutra/MD, a supplement company with products designed to diminish the side effects of commonly prescribed medications. He has recently been elected to the Examining Committee for the American Clinical Board of Nutrition. He can be reached at 281-240-2229 or on the web at http://www.essental-nutrients.net
Article Source: http://EzineArticles.com/?expert=Peter_Osborne
Technorati
Thursday, October 16, 2008
Your Medication May Be Causing Malnutrition
In today's society, prescription medications are very commonly used to treat disease, but what most doctors don't realize is that many of these drugs can cause deficiencies of vitamins, minerals, and other important nutrients required for normal body functions. Some of these functions include energy production, protection against free radicals, and repairing and replacing worn out cells of the heart, lungs, skin, bone, etc. Initially these deficiencies equate to generalized symptoms such as fatigue, dry scaly skin, weight gain, depression, difficulty sleeping, muscle stiffness, joint aches and pains, and poor memory. Over longer periods, these nutrient deficiencies can lead to a faster progression toward chronic degenerative diseases like cancer, dementia, heart disease, osteoporosis, diabetes, cataracts, etc.
How come my doctor has never mentioned this to me before?
Simple, your doctor was most likely not trained in nutrition. Yes, you read correctly. Most medical schools do not even offer classes in nutrition, so if you doctor wanted to receive training in this area, he/she would have to seek it out elsewhere. Currently, there is a grass roots effort in place to teach physicians about medication induced nutritional deficiencies, but until this information becomes part of the medical curriculum, you should take measures on your own to ensure that your nutritional status remains intact when you are taking a medication with known nutrient depleting side effects.
CATCH 22 - In order to prevent heart disease doctors prescribe preventative medicines to lower cholesterol (statins), lower blood pressure (diuretics), thin the blood (aspirin), and reduce inflammation (NSAIDS). Collectively, these medicines can lead to deficiencies of coenzyme Q10, vitamin B1, vitamin C, folic acid, vitamin B-12, iron, potassium, calcium, magnesium, selenium, zinc, vitamin D, vitamin A, vitamin E, and beta carotene. Why is this harmful?
Example 1: Medications which lower cholesterol are given to reduce the risks for heart disease, but they can also cause a deficiency of CoQ10 inside the body. A deficiency of CoQ10 is linked to congestive heart failure and high blood pressure. Thus taking the medication over long periods of time may actually increase the risk for heart disease.
Example 2: Medications which lower blood pressure can induce deficiencies of calcium, magnesium, and potassium. Research now shows that a deficiency in these minerals can cause high blood pressure. Additionally, many blood pressure medications also deplete CoQ10.
Example 3: Taking aspirin thins the blood, but this may also cause deficiencies in folic acid and vitamin C. Folic acid deficiency causes elevations of a harmful chemical in your blood called homocysteine. Elevated homocysteine is an independent risk factor for heart disease, cancer, Alzheimer's disease, and osteoporosis. Vitamin C deficiency reduces the body's overall antioxidant status. Poor antioxidant function is associated with every known chronic degenerative disease.
Common Sense Applies: Although many of the above medications have been shown to give benefit when treating common conditions, they have also been shown in studies to reduce certain nutrient levels. Because we know that long term nutrient deficiencies can and do play a major role in the development of chronic degenerative disease, it only makes sense to take a common sense approach and address these nutrient deficiencies before they become a serious medical problem. Ask your doctor to monitor your nutrient levels with the appropriate lab work (Spectra Cell labs has a very comprehensive test to monitor nutrient deficiencies). Find out which nutrients your medication may be depleting and address them with proper supplementation. Remember that an ounce of prevention is worth a pound of cure!
To learn more about medications and the nutrients they deplete visit:
www.essential-nutrients.net
Dr. Peter Osborne, D.C., D.A.C.B.N. is the clinical director of Town Center Wellness in Sugar Land, TX. His practice focuses on integrative holistic care to include chiropractic, decompression, lifestyle coaching, as well as treating complex medical problems by identifying and correcting nutritional deficiencies through the use of specialized laboratory testing. He is a professor of nutrition for Houston Community College's nursing programs. He has designed several formulations for different supplement companies including The "Ath-Elite" Protocol, a product customized for professional athletes. He is a member of the ACA Council on Nutrition, the American Association for Health Freedom, a Diplomate with the American Clinical Board of Nutrition, and a co-founder of Nutra/MD, a supplement company with products designed to diminish the side effects of commonly prescribed medications. He has recently been elected to the Examining Committee for the American Clinical Board of Nutrition. He can be reached at 281-240-2229 or on the web at http://www.essential-nutrients.net
Article Source: http://EzineArticles.com/?expert=Peter_Osborne
How come my doctor has never mentioned this to me before?
Simple, your doctor was most likely not trained in nutrition. Yes, you read correctly. Most medical schools do not even offer classes in nutrition, so if you doctor wanted to receive training in this area, he/she would have to seek it out elsewhere. Currently, there is a grass roots effort in place to teach physicians about medication induced nutritional deficiencies, but until this information becomes part of the medical curriculum, you should take measures on your own to ensure that your nutritional status remains intact when you are taking a medication with known nutrient depleting side effects.
CATCH 22 - In order to prevent heart disease doctors prescribe preventative medicines to lower cholesterol (statins), lower blood pressure (diuretics), thin the blood (aspirin), and reduce inflammation (NSAIDS). Collectively, these medicines can lead to deficiencies of coenzyme Q10, vitamin B1, vitamin C, folic acid, vitamin B-12, iron, potassium, calcium, magnesium, selenium, zinc, vitamin D, vitamin A, vitamin E, and beta carotene. Why is this harmful?
Example 1: Medications which lower cholesterol are given to reduce the risks for heart disease, but they can also cause a deficiency of CoQ10 inside the body. A deficiency of CoQ10 is linked to congestive heart failure and high blood pressure. Thus taking the medication over long periods of time may actually increase the risk for heart disease.
Example 2: Medications which lower blood pressure can induce deficiencies of calcium, magnesium, and potassium. Research now shows that a deficiency in these minerals can cause high blood pressure. Additionally, many blood pressure medications also deplete CoQ10.
Example 3: Taking aspirin thins the blood, but this may also cause deficiencies in folic acid and vitamin C. Folic acid deficiency causes elevations of a harmful chemical in your blood called homocysteine. Elevated homocysteine is an independent risk factor for heart disease, cancer, Alzheimer's disease, and osteoporosis. Vitamin C deficiency reduces the body's overall antioxidant status. Poor antioxidant function is associated with every known chronic degenerative disease.
Common Sense Applies: Although many of the above medications have been shown to give benefit when treating common conditions, they have also been shown in studies to reduce certain nutrient levels. Because we know that long term nutrient deficiencies can and do play a major role in the development of chronic degenerative disease, it only makes sense to take a common sense approach and address these nutrient deficiencies before they become a serious medical problem. Ask your doctor to monitor your nutrient levels with the appropriate lab work (Spectra Cell labs has a very comprehensive test to monitor nutrient deficiencies). Find out which nutrients your medication may be depleting and address them with proper supplementation. Remember that an ounce of prevention is worth a pound of cure!
To learn more about medications and the nutrients they deplete visit:
www.essential-nutrients.net
Dr. Peter Osborne, D.C., D.A.C.B.N. is the clinical director of Town Center Wellness in Sugar Land, TX. His practice focuses on integrative holistic care to include chiropractic, decompression, lifestyle coaching, as well as treating complex medical problems by identifying and correcting nutritional deficiencies through the use of specialized laboratory testing. He is a professor of nutrition for Houston Community College's nursing programs. He has designed several formulations for different supplement companies including The "Ath-Elite" Protocol, a product customized for professional athletes. He is a member of the ACA Council on Nutrition, the American Association for Health Freedom, a Diplomate with the American Clinical Board of Nutrition, and a co-founder of Nutra/MD, a supplement company with products designed to diminish the side effects of commonly prescribed medications. He has recently been elected to the Examining Committee for the American Clinical Board of Nutrition. He can be reached at 281-240-2229 or on the web at http://www.essential-nutrients.net
Article Source: http://EzineArticles.com/?expert=Peter_Osborne
Chiropractic Fraud - Perception Vs Reality
Is health care fraud more prevalent in claims submitted by chiropractors than those submitted by members of other health care disciplines? When looking at the various news-sources, chiropractors are not found to make up either the lion-share of health care fraud charges or convictions reported.
Unfortunately, instances of fraud & abuse are present in ALL health care disciplines - Chiropractic, Medicine, Physical Therapy, etc. There is no single discipline that can lay claim to a proportionately higher rate of fraudulent conduct than any other health care discipline. However, despite this fact, there is an ongoing feeding-frenzy of insurers investigating chiropractic claims. These investigations go beyond simply evaluating either the merits or medical necessity of claims to determine if they should be paid.
Insurers are conducting 'post-payment' audits of claims paid in years past - focusing on purported documentation deficiencies in an effort to open the door for carriers to demand the money back! Chiropractors have found themselves faced with large refund demands from insurers. Why?
Is it because the services were not performed? No, the insurer verifies the performance of the services through talking with the patient. Is it because the chiropractor did not document having performed the service? No, the services in question are customarily documented as having been performed. Post-payment audits arise because the insurer has retroactively concluded, perhaps based upon some sense of entitlement, that the services were not documented sufficiently - i.e., to their satisfaction!
Insurers demanding refunds from providers for payments made - armed with allegations that providers failed to adequately document the services that were billed - file complaints with licensing & regulatory boards of the providers. If such complaints are made the real test will be in proving the documentation and standards were not met. The standards for documentation, as well as all other practice activity, for health care providers is established and defined by state health care licensing & regulatory boards. The boards, NOT the insurance companies, or managed care organizations, provide administrative oversight of the activity of licensees with sanctions for those who violate the laws and rules.
Allstate Insurance has established a clear-cut policy of suing chiropractors, alleging fraud and issuing press releases with the fanfare of a New Year's Day parade. News sources, including chiropractic periodicals, do little or nothing to either investigate or evaluate the factual bases of these suits prior to joining in lock-step to print the release giving Allstate the press it so desires.
The news media and public-at-large tend to believe that if Allstate sues a health care provider, alleging fraud, the provider must have engaged in fraudulent activities. It must mean that Allstate believes both they and their insured - were somehow defrauded by the provider's actions or conduct. It must also mean that Allstate relied upon the provider's misrepresentations when paying claims?
Well, that certainly was not the case according to the September 2007 decision rendered by the United States 5th Circuit Court of Appeals in the case of Allstate Insurance Co. et al. v. Receivables Finance Company, LLC et al. The Opinion handed down by the Court was that Allstate is a major player in the casualty business - thus when Allstate routinely reviews a health care bill submitted by a chiropractor, performs some form of utilization review on the provider's bill and ends up paying a significantly reduced sum based on the explanation that Allstate believed that a significant portion of the bill was either medically unnecessary or not properly documented and thus not subject to payment - Allstate cannot later come back and sue the same provider claiming that it was defrauded by some scam perpetrated by that same provider.
Nor was it the case, based on my personal knowledge, having worked with Accident & Injury Chiropractic ("A&I"), a named defendant in the case. In 1998, following the execution of search warrants by federal authorities, I assisted A&I on implementing a Health Care Compliance program, a program designed to detect and correct any improper, false or fraudulent action by the company and/or its health care providers- primarily chiropractors. Following A&I's implementation of their compliance program, the federal investigation was formally closed.
The Compliance program that A&I implemented included an intensive internal auditing, monitoring and reporting system to facilitate the identification and correction of any form(s) of misconduct. The Compliance program was well-publicized to insurers and others, who were invited to report their concerns relative to alleged improper conduct and/or activities of the clinics, as well as those chiropractors associated, to A&I's Compliance Board to have those concerns appropriately addressed.
Allstate was well aware of A&I's Compliance program implementation, but never, to my knowledge, reported any concerns Allstate had, Allstate alleged in its highly publicized lawsuit, to the Compliance Board. It is significant to note that, while other insurers in positions similar to that of Allstate, did report concerns and such concerns were sufficiently addressed and corrected to the insurers' satisfaction.
Although an integral part of the creation and implementation of A&I's Compliance program, the only contact I had with Allstate was after it had filed its lawsuit. This contact consisted of speaking with a paralegal of Allstate's attorney. The paralegal indicated she understood that I had assisted A&I with its Compliance program and Allstate's attorney would like to talk with me. On no occasion did I ever speak with Allstate's attorney. The only reason that I did not talk with Allstate's attorney is that Allstate's attorney refused to serve me with domesticated process as an out-of-state witness.
This brings us to Allstate's suit filed in Federal Court in Dallas, Texas in March 2008, viz, Allstate et al. v. Michael K. Plambeck, D.C., Chiropractic Strategies et al. In this suit, Allstate alleges that Plambeck, who owns and operates Chiropractic Strategies Group ("CSG"), orchestrated a multi-state scam involving doctors, lawyers and telemarketers cleverly designed to solicit auto accident victims for free chiropractic evaluations - asserting that these free screenings were some form of subterfuge to enable CSG doctors to "inform" the patients they had severe injuries and to encourage the patients to sign up for legal representation by attorneys in order to prosecute claims for insurance recoveries and/or to participate in lawsuits against Allstate Insurance.
In a March 6, 2008 press release, Allstate reported that the lawsuit against Plambeck was filed following an extensive investigation by their Special Investigative Unit. Edward Moran, Allstate assistant Vice President in charge of the Special Investigation Unit, was quoted as stating, "Insurance fraud is a billion dollar business that costs the average consumer $300 in higher insurance premiums every year... Allstate is aggressively pursuing the fight against insurance fraud to protect consumers and help keep insurance costs down".
This must have been an extensive investigation by Allstate's special investigators! For more than 10 years Allstate has known of the manner in which Dr. Plambeck conducted and operated his chiropractic clinics, as described in its press release!
As a Special Agent for the National Insurance Crime Bureau (NICB) I, as well as other investigative agencies - including Allstate, was familiar more than a decade ago with the specific type of alleged acts of misconduct described. In fact, Allstate's Complaint identified activity back to 1996.
Nothing new was found in the information provided in the (2008) release - except that the average costs passed on to insurance consumers by insurance companies has now risen to $300.00. This is up from figures of $100 to $200 cited in previous years.
Talk about righteous indignation, the major casualty insurance companies regularly complains in the media that those high costs they pass on to the public are the result of health care fraud on the part of chiropractors and other health care professionals. However, carriers rarely, if ever, mention that they operate out of luxurious office complexes and pay multi-million dollar salaries to their executives.
For example, the CEO of Allstate, in his first year on the job, received an annual compensation package worth over $10.7 million, while the departing CEO, received $18.8 million annually and $25.4 million in retirement benefits. Don't think for a minute that those costs are not passed on to consumers in the form of rate increases!
Allstate's press release on Plambeck contained a 'Call to Action,' asking persons who have knowledge of, or have been victimized by, the scheme alleged in a lawsuit filed against the chiropractic industry to report this information to the NICB. Why should this information be reported to NICB?
Is the NICB, a quasi-governmental law enforcement agency, assisting Allstate with civil litigation against Plambeck? Does NICB have a concurrent extensive decade-long criminal investigation of Plambeck's activities?
NICB is a not-for-profit corporation under Section 501(c) (4) of the Internal Revenue Code as a social welfare organization - to combat fraud and theft for the benefit of customers and the public through information analysis, forecasting, criminal investigation support, training, and public awareness.
I suspect that NICB will do what Allstate says. Allstate is one of its biggest customers and funding source! This would include helping them on civil cases because that is what they did in the case referenced above. In A&I's discovery-filings against Allstate, A&I accessed information from Allstate that included NICB claims and financial checks conducted on me!
Is the filing of a lawsuit based on information known for over a decade, and the parallel effort to sway public opinion to its point of view, the most appropriate way to aggressively pursue the fight against insurance fraud?
According to a March 7, 2008 article in the Dallas Morning News - Bill Mellander, spokesman for Allstate's Special Investigative Unit, reports Allstate's adjusters are trained to identify common fraud indicators, such as similarities in dollar amounts or wording in paperwork. When such indicators appear in a health care claim Allstate's concerns are forwarded to Allstate's special investigative units who then look for wider trends that may point to health care fraud and abuse - perhaps perpetrated through some form of a scam. And, per Mellander, that's exactly what happened with respect to Allstate's investigation of Plambeck et al. and its taking this action in an attempt to recover dollars from fraudulent claims purportedly paid by Allstate.
I suspect Allstate adjusters are trained to do more than just identify fraudulent trends and forward such concerns to Allstate's SIU investigators as reported by Mr. Mellander. They have also been trained on how to evaluate claims submitted to determine if they should be paid utilizing sophisticated insurance industry software programs, such as Colossus, or local peer review doctors who are paid by the insurance industry to review and reduce provider claims by significant sums.
These trained adjusters probably interviewed the patients being treated at Plambeck's clinics to determine the following: (1) circumstances of the accident; (2) whether they were hurt; (3) what were their complaints of injury; (4) did they seek medical attention; and (5) are they still being treated.
Why were there no patients identified as co-defendants in Allstate's lawsuit alleging fraud and a collusive scheme in either the A&I or Plambeck cases? In order for such a "scheme" to exist, there must have been some form of patient claim submitted for payment that Allstate deemed to be fraudulent. If that is the case, are not the "patients" who submit the so-called fraudulent claim responsible for their own conduct? Wouldn't such a scheme, as alleged by Allstate, only be successful if you had willing-accident victims to participate? Not according to Allstate's actions.
Is paying claims and later filing a federal lawsuit seeking $10 million in an attempt to recover dollars paid on the claims by alleging fraud for activity known for over a decade the way to protect consumers and help keep insurance costs down?
In the Spring 2008 edition of Fraud Focus published by The Coalition Against Insurance Fraud, where it is reported that Plambeck allegedly cost Allstate so much money that the insurer is trying to "gut his operation" with a $10-million federal lawsuit. It is interesting to note that Mr. Moran, an Allstate Vice President, and NICB's CEO are both on the Board of Directors for the Coalition Against Insurance Fraud.
If Plambeck et al. named in Allstate's lawsuit are in fact engaged in fraudulent activity, then they should be dealt with appropriately and held accountable by the appropriate authorities - but not by an insurer, functioning as a de facto Attorney General, that wants to "gut them" in the public eye - through media releases and press conferences!
Allstate pays NICB large sums of money to facilitate criminal prosecutions of just the type of activity it alleged in its 2008 press release. The NICB, in a 2006 Special Edition of NICB Upclose, states, "Just what the doctor ordered... NICB now has more than 25 Medical Fraud Task Force Units throughout the United States that are creating a big return on investment for NICB members". Interestingly, NICB reports having task force units in all the states identified in Allstate et al. v. Plambeck et al.
Could this desire to gut chiropractic businesses also be the reason for their lawsuits against so many other chiropractors? It definitely appeared to be the case with a chiropractor on the east coast who operated a number of multidiscipline practices. I assisted this provider with his Compliance program. This provider's business was in fact "gutted" and forced into bankruptcy trying to pay legal fees to defend the lawsuit of the "Good-Hands" people.
Are Allstate's protestations that it innocently relied on Plambeck's representations, and was defrauded thereby, plausible? Does the fact that Allstate has been investigating Plambeck for more than a decade militate against Allstate's claim that it "relied" on Plambeck's representations to its detriment?
This issue of reliance is the lynchpin of a fraud claim. If one is convinced that another party is a fraud, and proceeds to transact business with that party, may the aggrieved party subsequently cry, "Fraud"?
May Allstate, the "good hands people," also claim to be the "clean hands people"?
Health care fraud may be a billion dollar business as Mr. Moran states - but the insurance industry is definitely a TRILLION dollar business!
It is disingenuous for Allstate to report its fight against insurance fraud is to protect consumers and help keep insurance costs down.
In a August 18, 2005 press release on yet another federal lawsuit filed against chiropractic, this one in Massachusetts against First Spine and Rehab, Allstate reported that since 2001 Allstate has received more than $55 million in court judgments, where Mr. Moran states, "These judgments against criminals range from individuals to sophisticated organized crime syndicates." Interestingly, Allstate's press releases dating back to 2004 found on their web-site reveals that all but one of the releases relevant to its lawsuits against health care providers involved chiropractors.
It should be noted that The American Association of Justice ranks Allstate Insurance as the worst insurer for consumers, showing a pattern of greed, refusal to pay legitimate claims, and rewarding employees for claim denials with a strategy of "deny, delay, and defend".
In my more than twenty years of working with health care fraud-fighters - including insurers, regulators, law enforcers and health care providers, the one constant I have found relating to chiropractic fraud is that those in the position to make the biggest difference choose to invest the least amount possible in learning how to identify, how to investigate, how to prosecute, and STOP HEALTH CARE FRAUD!
However, these same entities/individuals are likely to COMPLAIN the loudest about how bad the problem is!
This niche targeting of chiropractors by insurers for post-payment audits and civil lawsuits does nothing to really reduce HEALTHCARE FRAUD but are diversion tactics to make everyone think that something is being done.
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Unfortunately, instances of fraud & abuse are present in ALL health care disciplines - Chiropractic, Medicine, Physical Therapy, etc. There is no single discipline that can lay claim to a proportionately higher rate of fraudulent conduct than any other health care discipline. However, despite this fact, there is an ongoing feeding-frenzy of insurers investigating chiropractic claims. These investigations go beyond simply evaluating either the merits or medical necessity of claims to determine if they should be paid.
Insurers are conducting 'post-payment' audits of claims paid in years past - focusing on purported documentation deficiencies in an effort to open the door for carriers to demand the money back! Chiropractors have found themselves faced with large refund demands from insurers. Why?
Is it because the services were not performed? No, the insurer verifies the performance of the services through talking with the patient. Is it because the chiropractor did not document having performed the service? No, the services in question are customarily documented as having been performed. Post-payment audits arise because the insurer has retroactively concluded, perhaps based upon some sense of entitlement, that the services were not documented sufficiently - i.e., to their satisfaction!
Insurers demanding refunds from providers for payments made - armed with allegations that providers failed to adequately document the services that were billed - file complaints with licensing & regulatory boards of the providers. If such complaints are made the real test will be in proving the documentation and standards were not met. The standards for documentation, as well as all other practice activity, for health care providers is established and defined by state health care licensing & regulatory boards. The boards, NOT the insurance companies, or managed care organizations, provide administrative oversight of the activity of licensees with sanctions for those who violate the laws and rules.
Allstate Insurance has established a clear-cut policy of suing chiropractors, alleging fraud and issuing press releases with the fanfare of a New Year's Day parade. News sources, including chiropractic periodicals, do little or nothing to either investigate or evaluate the factual bases of these suits prior to joining in lock-step to print the release giving Allstate the press it so desires.
The news media and public-at-large tend to believe that if Allstate sues a health care provider, alleging fraud, the provider must have engaged in fraudulent activities. It must mean that Allstate believes both they and their insured - were somehow defrauded by the provider's actions or conduct. It must also mean that Allstate relied upon the provider's misrepresentations when paying claims?
Well, that certainly was not the case according to the September 2007 decision rendered by the United States 5th Circuit Court of Appeals in the case of Allstate Insurance Co. et al. v. Receivables Finance Company, LLC et al. The Opinion handed down by the Court was that Allstate is a major player in the casualty business - thus when Allstate routinely reviews a health care bill submitted by a chiropractor, performs some form of utilization review on the provider's bill and ends up paying a significantly reduced sum based on the explanation that Allstate believed that a significant portion of the bill was either medically unnecessary or not properly documented and thus not subject to payment - Allstate cannot later come back and sue the same provider claiming that it was defrauded by some scam perpetrated by that same provider.
Nor was it the case, based on my personal knowledge, having worked with Accident & Injury Chiropractic ("A&I"), a named defendant in the case. In 1998, following the execution of search warrants by federal authorities, I assisted A&I on implementing a Health Care Compliance program, a program designed to detect and correct any improper, false or fraudulent action by the company and/or its health care providers- primarily chiropractors. Following A&I's implementation of their compliance program, the federal investigation was formally closed.
The Compliance program that A&I implemented included an intensive internal auditing, monitoring and reporting system to facilitate the identification and correction of any form(s) of misconduct. The Compliance program was well-publicized to insurers and others, who were invited to report their concerns relative to alleged improper conduct and/or activities of the clinics, as well as those chiropractors associated, to A&I's Compliance Board to have those concerns appropriately addressed.
Allstate was well aware of A&I's Compliance program implementation, but never, to my knowledge, reported any concerns Allstate had, Allstate alleged in its highly publicized lawsuit, to the Compliance Board. It is significant to note that, while other insurers in positions similar to that of Allstate, did report concerns and such concerns were sufficiently addressed and corrected to the insurers' satisfaction.
Although an integral part of the creation and implementation of A&I's Compliance program, the only contact I had with Allstate was after it had filed its lawsuit. This contact consisted of speaking with a paralegal of Allstate's attorney. The paralegal indicated she understood that I had assisted A&I with its Compliance program and Allstate's attorney would like to talk with me. On no occasion did I ever speak with Allstate's attorney. The only reason that I did not talk with Allstate's attorney is that Allstate's attorney refused to serve me with domesticated process as an out-of-state witness.
This brings us to Allstate's suit filed in Federal Court in Dallas, Texas in March 2008, viz, Allstate et al. v. Michael K. Plambeck, D.C., Chiropractic Strategies et al. In this suit, Allstate alleges that Plambeck, who owns and operates Chiropractic Strategies Group ("CSG"), orchestrated a multi-state scam involving doctors, lawyers and telemarketers cleverly designed to solicit auto accident victims for free chiropractic evaluations - asserting that these free screenings were some form of subterfuge to enable CSG doctors to "inform" the patients they had severe injuries and to encourage the patients to sign up for legal representation by attorneys in order to prosecute claims for insurance recoveries and/or to participate in lawsuits against Allstate Insurance.
In a March 6, 2008 press release, Allstate reported that the lawsuit against Plambeck was filed following an extensive investigation by their Special Investigative Unit. Edward Moran, Allstate assistant Vice President in charge of the Special Investigation Unit, was quoted as stating, "Insurance fraud is a billion dollar business that costs the average consumer $300 in higher insurance premiums every year... Allstate is aggressively pursuing the fight against insurance fraud to protect consumers and help keep insurance costs down".
This must have been an extensive investigation by Allstate's special investigators! For more than 10 years Allstate has known of the manner in which Dr. Plambeck conducted and operated his chiropractic clinics, as described in its press release!
As a Special Agent for the National Insurance Crime Bureau (NICB) I, as well as other investigative agencies - including Allstate, was familiar more than a decade ago with the specific type of alleged acts of misconduct described. In fact, Allstate's Complaint identified activity back to 1996.
Nothing new was found in the information provided in the (2008) release - except that the average costs passed on to insurance consumers by insurance companies has now risen to $300.00. This is up from figures of $100 to $200 cited in previous years.
Talk about righteous indignation, the major casualty insurance companies regularly complains in the media that those high costs they pass on to the public are the result of health care fraud on the part of chiropractors and other health care professionals. However, carriers rarely, if ever, mention that they operate out of luxurious office complexes and pay multi-million dollar salaries to their executives.
For example, the CEO of Allstate, in his first year on the job, received an annual compensation package worth over $10.7 million, while the departing CEO, received $18.8 million annually and $25.4 million in retirement benefits. Don't think for a minute that those costs are not passed on to consumers in the form of rate increases!
Allstate's press release on Plambeck contained a 'Call to Action,' asking persons who have knowledge of, or have been victimized by, the scheme alleged in a lawsuit filed against the chiropractic industry to report this information to the NICB. Why should this information be reported to NICB?
Is the NICB, a quasi-governmental law enforcement agency, assisting Allstate with civil litigation against Plambeck? Does NICB have a concurrent extensive decade-long criminal investigation of Plambeck's activities?
NICB is a not-for-profit corporation under Section 501(c) (4) of the Internal Revenue Code as a social welfare organization - to combat fraud and theft for the benefit of customers and the public through information analysis, forecasting, criminal investigation support, training, and public awareness.
I suspect that NICB will do what Allstate says. Allstate is one of its biggest customers and funding source! This would include helping them on civil cases because that is what they did in the case referenced above. In A&I's discovery-filings against Allstate, A&I accessed information from Allstate that included NICB claims and financial checks conducted on me!
Is the filing of a lawsuit based on information known for over a decade, and the parallel effort to sway public opinion to its point of view, the most appropriate way to aggressively pursue the fight against insurance fraud?
According to a March 7, 2008 article in the Dallas Morning News - Bill Mellander, spokesman for Allstate's Special Investigative Unit, reports Allstate's adjusters are trained to identify common fraud indicators, such as similarities in dollar amounts or wording in paperwork. When such indicators appear in a health care claim Allstate's concerns are forwarded to Allstate's special investigative units who then look for wider trends that may point to health care fraud and abuse - perhaps perpetrated through some form of a scam. And, per Mellander, that's exactly what happened with respect to Allstate's investigation of Plambeck et al. and its taking this action in an attempt to recover dollars from fraudulent claims purportedly paid by Allstate.
I suspect Allstate adjusters are trained to do more than just identify fraudulent trends and forward such concerns to Allstate's SIU investigators as reported by Mr. Mellander. They have also been trained on how to evaluate claims submitted to determine if they should be paid utilizing sophisticated insurance industry software programs, such as Colossus, or local peer review doctors who are paid by the insurance industry to review and reduce provider claims by significant sums.
These trained adjusters probably interviewed the patients being treated at Plambeck's clinics to determine the following: (1) circumstances of the accident; (2) whether they were hurt; (3) what were their complaints of injury; (4) did they seek medical attention; and (5) are they still being treated.
Why were there no patients identified as co-defendants in Allstate's lawsuit alleging fraud and a collusive scheme in either the A&I or Plambeck cases? In order for such a "scheme" to exist, there must have been some form of patient claim submitted for payment that Allstate deemed to be fraudulent. If that is the case, are not the "patients" who submit the so-called fraudulent claim responsible for their own conduct? Wouldn't such a scheme, as alleged by Allstate, only be successful if you had willing-accident victims to participate? Not according to Allstate's actions.
Is paying claims and later filing a federal lawsuit seeking $10 million in an attempt to recover dollars paid on the claims by alleging fraud for activity known for over a decade the way to protect consumers and help keep insurance costs down?
In the Spring 2008 edition of Fraud Focus published by The Coalition Against Insurance Fraud, where it is reported that Plambeck allegedly cost Allstate so much money that the insurer is trying to "gut his operation" with a $10-million federal lawsuit. It is interesting to note that Mr. Moran, an Allstate Vice President, and NICB's CEO are both on the Board of Directors for the Coalition Against Insurance Fraud.
If Plambeck et al. named in Allstate's lawsuit are in fact engaged in fraudulent activity, then they should be dealt with appropriately and held accountable by the appropriate authorities - but not by an insurer, functioning as a de facto Attorney General, that wants to "gut them" in the public eye - through media releases and press conferences!
Allstate pays NICB large sums of money to facilitate criminal prosecutions of just the type of activity it alleged in its 2008 press release. The NICB, in a 2006 Special Edition of NICB Upclose, states, "Just what the doctor ordered... NICB now has more than 25 Medical Fraud Task Force Units throughout the United States that are creating a big return on investment for NICB members". Interestingly, NICB reports having task force units in all the states identified in Allstate et al. v. Plambeck et al.
Could this desire to gut chiropractic businesses also be the reason for their lawsuits against so many other chiropractors? It definitely appeared to be the case with a chiropractor on the east coast who operated a number of multidiscipline practices. I assisted this provider with his Compliance program. This provider's business was in fact "gutted" and forced into bankruptcy trying to pay legal fees to defend the lawsuit of the "Good-Hands" people.
Are Allstate's protestations that it innocently relied on Plambeck's representations, and was defrauded thereby, plausible? Does the fact that Allstate has been investigating Plambeck for more than a decade militate against Allstate's claim that it "relied" on Plambeck's representations to its detriment?
This issue of reliance is the lynchpin of a fraud claim. If one is convinced that another party is a fraud, and proceeds to transact business with that party, may the aggrieved party subsequently cry, "Fraud"?
May Allstate, the "good hands people," also claim to be the "clean hands people"?
Health care fraud may be a billion dollar business as Mr. Moran states - but the insurance industry is definitely a TRILLION dollar business!
It is disingenuous for Allstate to report its fight against insurance fraud is to protect consumers and help keep insurance costs down.
In a August 18, 2005 press release on yet another federal lawsuit filed against chiropractic, this one in Massachusetts against First Spine and Rehab, Allstate reported that since 2001 Allstate has received more than $55 million in court judgments, where Mr. Moran states, "These judgments against criminals range from individuals to sophisticated organized crime syndicates." Interestingly, Allstate's press releases dating back to 2004 found on their web-site reveals that all but one of the releases relevant to its lawsuits against health care providers involved chiropractors.
It should be noted that The American Association of Justice ranks Allstate Insurance as the worst insurer for consumers, showing a pattern of greed, refusal to pay legitimate claims, and rewarding employees for claim denials with a strategy of "deny, delay, and defend".
In my more than twenty years of working with health care fraud-fighters - including insurers, regulators, law enforcers and health care providers, the one constant I have found relating to chiropractic fraud is that those in the position to make the biggest difference choose to invest the least amount possible in learning how to identify, how to investigate, how to prosecute, and STOP HEALTH CARE FRAUD!
However, these same entities/individuals are likely to COMPLAIN the loudest about how bad the problem is!
This niche targeting of chiropractors by insurers for post-payment audits and civil lawsuits does nothing to really reduce HEALTHCARE FRAUD but are diversion tactics to make everyone think that something is being done.
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Criminals Who Happen to Be Doctors
The article below is from a 1997 article, however, many of the recipe items are still being used - one of the big differences today is that providers following the recipe are more careful on the reporting of comprehensive exams but the billing for physical medicine & rehabilitation services - especially, therapeutic procedures, has been inserted.
Can you imagine making a years income in a month's time? Would you like to know how to increase your weekly income $8,000 to $10,000? These are just some of the questions asked by national provider fraud organizations who recruit doctors with promises of wealth.
It is an unfortunate reality that some doctors have greed in mind, not patient care, and use patients as vehicles in their drive for wealth. And, for them, the soft tissue injury is just what the doctor ordered!
Soft tissue injuries are best described as any aberration of skin, muscle, ligament or tendon, to include sprains and strains and associated syndromes that are self-limiting in nature and will heal with or without treatment, where 90% are spontaneously resolved in 90 days. These are minor injuries that are subjectively identified from patient complaints, or what patients tell the doctor, and, for the most part, are objectively unverifiable, and virtually impossible to prove, or disprove. As a result, the soft tissue injury can be the perfect medical condition for fraud!
The National Insurance Crime Bureau (NICB), the property & casualty insurance industry's action arm against insurance crime, identifies the soft tissue injury as the typical fraud-related injury claim. And, reports that unscrupulous medical and legal providers have the largest monetary incentives to participate in this fraud. The NICB reports the frequency and costs of these claims are on the rise, revealing an Insurance Research Council study that reports soft tissue injuries were filed by 83% of claimants in at-fault auto accidents in 1992, up 75% from five years earlier, and claim costs are about four times higher, on average, than 15 years ago. The NICB estimates that the average American household pays an additional $200 each year in premiums to pay for the $20 BILLION annual insurance fraud problem!
This minor injury is a major problem for insurers and consumers - not by accident - but by the specific intent and design of the national provider fraud organizations, who travel the country to find doctors willing to do whatever it takes to make more money. Large numbers are attracted that want the riches advertised, and will do just that - whatever it takes! Here, the soft tissue injury is the perfect medical condition for fraud, as the prescription is to use soft tissue injuries, in blatant and costly fraud schemes, and follow a RECIPE FOR WEALTH! This recipe calls for specific ingredients:
Use any and all means, to include professional associations and solicitation scams, to get people with insurance in the door.
Turn everyone with insurance, regardless of medical condition or need, into patients.
Keep patients coming back, regardless of need, until the insurance runs-out, or is cut-off.
Bill insurers for comprehensive exams not provided, worthless diagnostic tests and unnecessary treatment.
Use aggressive tactics, the legal system and political connections to make insurers pay.
This recipe is only about making money, not making people better. We trust doctors have the experience, knowledge and commitment to make us better. We expect a lot from health care professionals, and most deliver in an honest and caring manner. However, the doctors following this recipe use their profession, position in society and out trust, to steal through costly exams, tests and treatments! Evident by looking at the ingredients above, especially numbers one and four.
Ingredient one is very troubling, not only for the financial impact it may cause, but more importantly for the public safety concern it creates for patients. This ingredient calls for doctors to seek out people with insurance, giving little or no regard to patient welfare, to be used as vehicles to steal. One of the more common tactics used to fulfill this ingredient are "FREE EXAMS", reportedly offered, as a public service by doctors concerned about our health-because we may be injured and not know it!
The "FREE EXAMS", offered through advertisements, coupons, store screenings, free dinners, phone calls and/or letters, are not public service! The "FREE EXAM" is a bait and switch scam; with the exam (BAIT) providing doctors the opportunity to hard sell people with insurance on the need for treatment and to become patients (SWITCH). The first thing "examined" is available insurance, identified from questionnaires, where actual injuries make little difference in the "FREE EXAM" scams, but available insurance is the basis for treatment. Doctors using this tactic are rolling the dice to find: INSURANCE = INCOME!
Consider the bait provided-"FREE EXAM", you may be hurt and not know it. Now, how could someone be hurt and not know it? I know when I am hurt, don't you? How do doctors diagnose soft tissue injuries on people who don't know they are hurt? If you are not hurt, will you have the (subjective) complaints the doctor needs to diagnose this condition? Further, why would a doctor examine us for free? Are the doctors really so concerned about our health that they will provide us with a free medical service? I don't think so, do you?
Favorite targets of these EXAMS are auto accident victims identified from police reports. The police report not only documents the auto accident, but also provides contact and insurance information on the victim (s). Both medical and legal professionals see money in the form of future insurance claims, and aggressively solicit auto accident victims by mail and phone. Victims may be contacted by multiple sources following accidents, even businesses located in other parts of the country who solicit for local professionals.
The fourth ingredient of the recipe is of particular interest and importance to fraud fighters, whereby completing this ingredient, doctors engage in provable, beyond a reasonable doubt, fraud! They bill for services impossible to provide, and for others that are absolutely worthless when diagnosing soft tissue injuries. If held accountable for the services billed, and, by knowing what the billing codes mean, we have powerful evidence to stop these doctors.
CURRENT PROCEDURAL TERMINOLOGY or CPT Codes are used by most medical providers, even doctors following the recipe, to get paid. The American Medical Association promulgated CPT Codes so that all providers could accurately report services and collect proper compensation. These codes are based on the amount of work done, judgment used and medical risks to patients, and instruct providers using the codes to select the code (s) that most accurately identifies the service (s) performed.
An easy way to determine what services were billed is to use the CPT Codes, and break the bills down by category of services: EXAMS-TESTS-TREATMENT. Calculate each category to find the respective totals billed. Typically, by breaking the bills down, we find that less than half of the doctor's bill is for treatment (services to assist patient's in getting to a better state of health), and the majority of the bill is for exams and tests. Additionally, patterns are identified wherein the exact same services are billed on all patients.
Further, if we know what is required by CPT on the services billed by the doctors following the recipe, we can establish our evidence to stop their costly schemes. These doctors are not selecting codes that most accurately identify their services. Many of the exams billed are comprehensive, which are impossible to perform on patients with soft tissue injury. Many of the tests billed purport objective data, which is impossible on a subjective injury. And, most of the treatment billed is limited to services that don't require a doctor to administer. Each service category deserves a closer look.
EXAMS - CPT has five levels of exams, based on the nature of the presenting medical problems and risks of patients, from problem focused (minimal) to comprehensive (serious). CPT reports three key components of an exam: 1) History, 2) Physical Exam, and 3) Medical Decisions. Each component will have varying requirements, depending on the level service reported, that must be met, or exceeded, to bill exam services. The more work and judgment required by the doctor and the higher the level of examination.
The recipe calls for doctors to bill for comprehensive exams. CPT reports it typically takes doctors 60 minutes, face to face with patients and/or family, to complete comprehensive exams, where doctors: 1) take a comprehensive history, 2) conduct a comprehensive physical exam, and 3) make moderate to high complexity medical decisions on patients with moderate to high risks of morbidity/mortality (death), and/or prolonged functional impairment without treatment. The comprehensive exam is extensive and is conducted on patients with serious medical problems.
Though investigations show it as a favorite billing code, these doctors fail to fulfill any of the required components of the comprehensive examinations. The medical risks of their soft tissue patients are far less than the risks inherent to patients that need comprehensive exams. Soft tissue injuries are not serious medical conditions. Does CPT have a code that accurately reflects the exam on a soft tissue patient? Yes, as a matter of fact it does, but it is not comprehensive, and, more importantly, it will not pay as well! Indicating, these highly educated and trained medical professionals knowingly avoid the proper exam code, and purposefully report a service not provided to steal!
TESTS-In addition, to misrepresenting the level of exams billed, the recipe calls for doctors to bill for expensive diagnostic tests. These tests purport objective data on the subjective soft tissue injury. Is this possible? Wouldn't this make the injuries objective? Even if possible, what difference would objective data have on a injury found only after the patient identified it, that will heal in time, with, or without treatment? The difference is to increase the patient's bill with charges for worthless tests. Typically, the tests, administered by an unlicensed assistant, in less than 10 minutes, on a specific body area, cost more than double what the doctor charged for their whole body examination.
CPT does not have specific codes for many of the tests billed by doctors following the recipe. However, the national provider fraud organizations will instruct what codes to use, to misrepresent the service provided. Most of these stated objective tests are not recognized clinically or scientifically, and do not provide the objective data claimed. For the most part, the tests are not even taught at accredited schools, but are taught in weekend seminars by those with a vested financial interest in the specific tests. This lack of validity hasn't stopped these doctors.
Wouldn't you think that in all the comprehensive exams reported and billed, that these doctors would have all the information needed to treat (a condition identified from what patients tell them)? The tests have little or nothing to do with making patients better, but are ingredients for wealth. The national provider fraud organizations chose the soft tissue injury as a foundation for wealth because one can't prove this injury doesn't exist. On the other hand, to make more money, they instruct tests be administered, to prove that the injury exists. They can't have it both ways!
TREATMENT - CPT reports numerous treatment codes, with specific requirements for each, broken into two types: 1) Doctor provided, and 2) Doctor supervised. Some codes require that the treatment only be provided by a doctor. Others require only that a doctor supervise the treatment-the correct treatment was provided, administered properly, on the right body area, and for the appropriate time. The treatment must have some relationship to the reported injury, and as such, treatment available for soft tissue injuries is limited, but the specific requirements must be met prior to billing treatment services.
The majority of treatment billed, by doctors following the recipe, will be the same on all patients; regardless of need or individual condition, and will be administered by unlicensed assistants. The recipe, with the specific purpose to make more money, results in doctors practicing a revolving door philosophy of medical care. Time is money, and to see as many patients as possible in a single day (some report close to a hundred), doctors shuffle patients in and out in less than 10 minutes. With all the "FREE EXAMS", comprehensive exams, and tests that are also reported, where do these doctors find the time to treat all these patients? Maybe, this is another reason the national organization chose the soft tissue injury - it is self-limiting and spontaneously resolving!
The national provider fraud organizations (practice builders) exact a heavy toll. These organizations attract large numbers, of highly educated and trained medical professionals, that want the riches advertised, who will knowingly and purposefully, engage in the costly and systematic fraud schemes advocated by the organizations, to get it. They are CRIMINALS, WHO HAPPEN TO BE DOCTORS! They have contempt for society; abuse their status, and our trust, to steal. They have little regard for the welfare of patients. They dare insurers to stop their blatant and costly fraud schemes. They vigorously use the legal system to guarantee success/compliance. They force consumers to endure the expense of their fraud.
They believe law enforcers have little or no interest in their crimes. In the end, think they are untouchable. A fatal mistake! Honest doctors are teaching fraud fighters the intricacies of medical provider fraud. Insurers, regulatory agencies and law enforcers are developing a more sophisticated attack. The political climate is such that two major issues, "health care" and "crime" are gaining much attention and focus at the highest level of government. Crimes such as these, committed by health care providers are being attacked by a coordinated fraud fighting team throughout the nation.
"The eyes only see what the mind knows", is a quote brought to my attention, some years back, by a medical professional committed to stopping this criminal activity, and is appropriate here. If one knows what the criminals, who happen to be doctors are doing - one can see how to stop them!
FIRST PUBLISHED: John Cooke Fraud Report, Jan/Feb 1997
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Can you imagine making a years income in a month's time? Would you like to know how to increase your weekly income $8,000 to $10,000? These are just some of the questions asked by national provider fraud organizations who recruit doctors with promises of wealth.
It is an unfortunate reality that some doctors have greed in mind, not patient care, and use patients as vehicles in their drive for wealth. And, for them, the soft tissue injury is just what the doctor ordered!
Soft tissue injuries are best described as any aberration of skin, muscle, ligament or tendon, to include sprains and strains and associated syndromes that are self-limiting in nature and will heal with or without treatment, where 90% are spontaneously resolved in 90 days. These are minor injuries that are subjectively identified from patient complaints, or what patients tell the doctor, and, for the most part, are objectively unverifiable, and virtually impossible to prove, or disprove. As a result, the soft tissue injury can be the perfect medical condition for fraud!
The National Insurance Crime Bureau (NICB), the property & casualty insurance industry's action arm against insurance crime, identifies the soft tissue injury as the typical fraud-related injury claim. And, reports that unscrupulous medical and legal providers have the largest monetary incentives to participate in this fraud. The NICB reports the frequency and costs of these claims are on the rise, revealing an Insurance Research Council study that reports soft tissue injuries were filed by 83% of claimants in at-fault auto accidents in 1992, up 75% from five years earlier, and claim costs are about four times higher, on average, than 15 years ago. The NICB estimates that the average American household pays an additional $200 each year in premiums to pay for the $20 BILLION annual insurance fraud problem!
This minor injury is a major problem for insurers and consumers - not by accident - but by the specific intent and design of the national provider fraud organizations, who travel the country to find doctors willing to do whatever it takes to make more money. Large numbers are attracted that want the riches advertised, and will do just that - whatever it takes! Here, the soft tissue injury is the perfect medical condition for fraud, as the prescription is to use soft tissue injuries, in blatant and costly fraud schemes, and follow a RECIPE FOR WEALTH! This recipe calls for specific ingredients:
Use any and all means, to include professional associations and solicitation scams, to get people with insurance in the door.
Turn everyone with insurance, regardless of medical condition or need, into patients.
Keep patients coming back, regardless of need, until the insurance runs-out, or is cut-off.
Bill insurers for comprehensive exams not provided, worthless diagnostic tests and unnecessary treatment.
Use aggressive tactics, the legal system and political connections to make insurers pay.
This recipe is only about making money, not making people better. We trust doctors have the experience, knowledge and commitment to make us better. We expect a lot from health care professionals, and most deliver in an honest and caring manner. However, the doctors following this recipe use their profession, position in society and out trust, to steal through costly exams, tests and treatments! Evident by looking at the ingredients above, especially numbers one and four.
Ingredient one is very troubling, not only for the financial impact it may cause, but more importantly for the public safety concern it creates for patients. This ingredient calls for doctors to seek out people with insurance, giving little or no regard to patient welfare, to be used as vehicles to steal. One of the more common tactics used to fulfill this ingredient are "FREE EXAMS", reportedly offered, as a public service by doctors concerned about our health-because we may be injured and not know it!
The "FREE EXAMS", offered through advertisements, coupons, store screenings, free dinners, phone calls and/or letters, are not public service! The "FREE EXAM" is a bait and switch scam; with the exam (BAIT) providing doctors the opportunity to hard sell people with insurance on the need for treatment and to become patients (SWITCH). The first thing "examined" is available insurance, identified from questionnaires, where actual injuries make little difference in the "FREE EXAM" scams, but available insurance is the basis for treatment. Doctors using this tactic are rolling the dice to find: INSURANCE = INCOME!
Consider the bait provided-"FREE EXAM", you may be hurt and not know it. Now, how could someone be hurt and not know it? I know when I am hurt, don't you? How do doctors diagnose soft tissue injuries on people who don't know they are hurt? If you are not hurt, will you have the (subjective) complaints the doctor needs to diagnose this condition? Further, why would a doctor examine us for free? Are the doctors really so concerned about our health that they will provide us with a free medical service? I don't think so, do you?
Favorite targets of these EXAMS are auto accident victims identified from police reports. The police report not only documents the auto accident, but also provides contact and insurance information on the victim (s). Both medical and legal professionals see money in the form of future insurance claims, and aggressively solicit auto accident victims by mail and phone. Victims may be contacted by multiple sources following accidents, even businesses located in other parts of the country who solicit for local professionals.
The fourth ingredient of the recipe is of particular interest and importance to fraud fighters, whereby completing this ingredient, doctors engage in provable, beyond a reasonable doubt, fraud! They bill for services impossible to provide, and for others that are absolutely worthless when diagnosing soft tissue injuries. If held accountable for the services billed, and, by knowing what the billing codes mean, we have powerful evidence to stop these doctors.
CURRENT PROCEDURAL TERMINOLOGY or CPT Codes are used by most medical providers, even doctors following the recipe, to get paid. The American Medical Association promulgated CPT Codes so that all providers could accurately report services and collect proper compensation. These codes are based on the amount of work done, judgment used and medical risks to patients, and instruct providers using the codes to select the code (s) that most accurately identifies the service (s) performed.
An easy way to determine what services were billed is to use the CPT Codes, and break the bills down by category of services: EXAMS-TESTS-TREATMENT. Calculate each category to find the respective totals billed. Typically, by breaking the bills down, we find that less than half of the doctor's bill is for treatment (services to assist patient's in getting to a better state of health), and the majority of the bill is for exams and tests. Additionally, patterns are identified wherein the exact same services are billed on all patients.
Further, if we know what is required by CPT on the services billed by the doctors following the recipe, we can establish our evidence to stop their costly schemes. These doctors are not selecting codes that most accurately identify their services. Many of the exams billed are comprehensive, which are impossible to perform on patients with soft tissue injury. Many of the tests billed purport objective data, which is impossible on a subjective injury. And, most of the treatment billed is limited to services that don't require a doctor to administer. Each service category deserves a closer look.
EXAMS - CPT has five levels of exams, based on the nature of the presenting medical problems and risks of patients, from problem focused (minimal) to comprehensive (serious). CPT reports three key components of an exam: 1) History, 2) Physical Exam, and 3) Medical Decisions. Each component will have varying requirements, depending on the level service reported, that must be met, or exceeded, to bill exam services. The more work and judgment required by the doctor and the higher the level of examination.
The recipe calls for doctors to bill for comprehensive exams. CPT reports it typically takes doctors 60 minutes, face to face with patients and/or family, to complete comprehensive exams, where doctors: 1) take a comprehensive history, 2) conduct a comprehensive physical exam, and 3) make moderate to high complexity medical decisions on patients with moderate to high risks of morbidity/mortality (death), and/or prolonged functional impairment without treatment. The comprehensive exam is extensive and is conducted on patients with serious medical problems.
Though investigations show it as a favorite billing code, these doctors fail to fulfill any of the required components of the comprehensive examinations. The medical risks of their soft tissue patients are far less than the risks inherent to patients that need comprehensive exams. Soft tissue injuries are not serious medical conditions. Does CPT have a code that accurately reflects the exam on a soft tissue patient? Yes, as a matter of fact it does, but it is not comprehensive, and, more importantly, it will not pay as well! Indicating, these highly educated and trained medical professionals knowingly avoid the proper exam code, and purposefully report a service not provided to steal!
TESTS-In addition, to misrepresenting the level of exams billed, the recipe calls for doctors to bill for expensive diagnostic tests. These tests purport objective data on the subjective soft tissue injury. Is this possible? Wouldn't this make the injuries objective? Even if possible, what difference would objective data have on a injury found only after the patient identified it, that will heal in time, with, or without treatment? The difference is to increase the patient's bill with charges for worthless tests. Typically, the tests, administered by an unlicensed assistant, in less than 10 minutes, on a specific body area, cost more than double what the doctor charged for their whole body examination.
CPT does not have specific codes for many of the tests billed by doctors following the recipe. However, the national provider fraud organizations will instruct what codes to use, to misrepresent the service provided. Most of these stated objective tests are not recognized clinically or scientifically, and do not provide the objective data claimed. For the most part, the tests are not even taught at accredited schools, but are taught in weekend seminars by those with a vested financial interest in the specific tests. This lack of validity hasn't stopped these doctors.
Wouldn't you think that in all the comprehensive exams reported and billed, that these doctors would have all the information needed to treat (a condition identified from what patients tell them)? The tests have little or nothing to do with making patients better, but are ingredients for wealth. The national provider fraud organizations chose the soft tissue injury as a foundation for wealth because one can't prove this injury doesn't exist. On the other hand, to make more money, they instruct tests be administered, to prove that the injury exists. They can't have it both ways!
TREATMENT - CPT reports numerous treatment codes, with specific requirements for each, broken into two types: 1) Doctor provided, and 2) Doctor supervised. Some codes require that the treatment only be provided by a doctor. Others require only that a doctor supervise the treatment-the correct treatment was provided, administered properly, on the right body area, and for the appropriate time. The treatment must have some relationship to the reported injury, and as such, treatment available for soft tissue injuries is limited, but the specific requirements must be met prior to billing treatment services.
The majority of treatment billed, by doctors following the recipe, will be the same on all patients; regardless of need or individual condition, and will be administered by unlicensed assistants. The recipe, with the specific purpose to make more money, results in doctors practicing a revolving door philosophy of medical care. Time is money, and to see as many patients as possible in a single day (some report close to a hundred), doctors shuffle patients in and out in less than 10 minutes. With all the "FREE EXAMS", comprehensive exams, and tests that are also reported, where do these doctors find the time to treat all these patients? Maybe, this is another reason the national organization chose the soft tissue injury - it is self-limiting and spontaneously resolving!
The national provider fraud organizations (practice builders) exact a heavy toll. These organizations attract large numbers, of highly educated and trained medical professionals, that want the riches advertised, who will knowingly and purposefully, engage in the costly and systematic fraud schemes advocated by the organizations, to get it. They are CRIMINALS, WHO HAPPEN TO BE DOCTORS! They have contempt for society; abuse their status, and our trust, to steal. They have little regard for the welfare of patients. They dare insurers to stop their blatant and costly fraud schemes. They vigorously use the legal system to guarantee success/compliance. They force consumers to endure the expense of their fraud.
They believe law enforcers have little or no interest in their crimes. In the end, think they are untouchable. A fatal mistake! Honest doctors are teaching fraud fighters the intricacies of medical provider fraud. Insurers, regulatory agencies and law enforcers are developing a more sophisticated attack. The political climate is such that two major issues, "health care" and "crime" are gaining much attention and focus at the highest level of government. Crimes such as these, committed by health care providers are being attacked by a coordinated fraud fighting team throughout the nation.
"The eyes only see what the mind knows", is a quote brought to my attention, some years back, by a medical professional committed to stopping this criminal activity, and is appropriate here. If one knows what the criminals, who happen to be doctors are doing - one can see how to stop them!
FIRST PUBLISHED: John Cooke Fraud Report, Jan/Feb 1997
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
TENS Increase Your Profit Margin?
Advertisements are being sent to doctors via facsimile in various parts of the United States from a California company asking them if TENS/EMS units are presently being prescribed to patients for home use? If not, this company reports that they can show how to give patients drugless pain relief and add a new profit center to the doctors office with TENS/EMS.
The company says their program is simple - they sell TENS to doctors for $29.00 (when 2 or more are purchased) EMS for $38 (when 2 or more purchased) and instruct the doctor on billing procedures for the TENS and fitting fee where the profits range from $200.00 to $600.00 per unit depending on the type of insurance coverage and amount charged for the unit/fitting fee. Next, the company indicates that they provide the patient with necessary supplies (batteries, pads & wires) and will bill the insurance company direct.
Good deal? Maybe.
Many state regulatory boards have prohibitions against excessive charges for health care services rendered - could the billing insurers $200 to $600 for providing a patient with a TENS the doctor purchased for $29 be considered excessive? What would the involved payer think of this activity - are they going to knowingly pay $200 to $600 for your providing the patient with a $29 TENS unit? And, what happens when insurance doesn't pay - is the patient going to be billed the higher rates for the $29 unit?
I would recommend that doctors ensure that this practice activity is consistent with their administrative laws, third-party payer rules and to check it out first with their attorney prior to use.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractics Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
The company says their program is simple - they sell TENS to doctors for $29.00 (when 2 or more are purchased) EMS for $38 (when 2 or more purchased) and instruct the doctor on billing procedures for the TENS and fitting fee where the profits range from $200.00 to $600.00 per unit depending on the type of insurance coverage and amount charged for the unit/fitting fee. Next, the company indicates that they provide the patient with necessary supplies (batteries, pads & wires) and will bill the insurance company direct.
Good deal? Maybe.
Many state regulatory boards have prohibitions against excessive charges for health care services rendered - could the billing insurers $200 to $600 for providing a patient with a TENS the doctor purchased for $29 be considered excessive? What would the involved payer think of this activity - are they going to knowingly pay $200 to $600 for your providing the patient with a $29 TENS unit? And, what happens when insurance doesn't pay - is the patient going to be billed the higher rates for the $29 unit?
I would recommend that doctors ensure that this practice activity is consistent with their administrative laws, third-party payer rules and to check it out first with their attorney prior to use.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractics Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Health Care Compliance, Buyer Beware
It should be no secret to health care providers of the government's recommendation that ALL health care professionals implement compliance programs to self-police their practices. With these recommendations numbers of health care professionals have implemented formal compliance programs.
Also with these recommendations a cottage industry was born for compliance companies to assist the health care professional, when needed, on implementing and administering compliance programs. The question for many health care professionals, when assistance is needed, is who to use...
Unfortuantely, numbers of so-called compliance companies have been created that appear to have minimal expertise and experience to provide the full-range (audit to administration) of appropriate guidance and have jumped on compliance as a means for some quick bucks.
For more than ten years I have been working with health care professionals to assist them on the implementation and administration of compliance programs, and, during this time I have heard some dandy stories and claims from health care professionals about compliance consultants - here are just a few recent ones:
A doctor called and asked if it were true that providers would get in trouble for not purchasing services from a speaker at a compliance seminar should federal investigators look at them, adding that the speaker told the seminar audience that he provides his list of seminar attendees to the FBI and that if one of the attendees were to be investigated by the Fed's their attendance would be used against them if they did not purchase his services.
In the more than 10 years of providing training for health care professionals I have never given or been asked by law enforcers for a list of attendees. But this speaker could in fact be giving his attendee list to the FBI - I don't know. With my investigator hat on, I can see how law enforcers could use this info for intelligence purposes but the info, in of itself, would be of minimal value unless there were suspicions that the health care professional was engaged in misconduct, and then it (attending the seminar) might be used in developed fraud cases with established evidence to support that the professional's violations of law were done purposefully - where the list might be of use to show the provider knew what they were doing was wrong and that they purposefully engaged in criminal conduct.
Another doctor, presently a compliance client, indicated that their previous compliance consultant used reported that by placing the (consultant's) compliance certificate on the wall in plain view for those coming into the clinic that if an investigator comes in and sees the certificate they will immediately turn around a leave because they will know the clinic is in compliance once they see his certificate.
Over the years I have heard of and seen people who wield a lot of power, but I have never heard of anyone in the compliance arena having that much power! And, I thought I had it going on.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street, Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Also with these recommendations a cottage industry was born for compliance companies to assist the health care professional, when needed, on implementing and administering compliance programs. The question for many health care professionals, when assistance is needed, is who to use...
Unfortuantely, numbers of so-called compliance companies have been created that appear to have minimal expertise and experience to provide the full-range (audit to administration) of appropriate guidance and have jumped on compliance as a means for some quick bucks.
For more than ten years I have been working with health care professionals to assist them on the implementation and administration of compliance programs, and, during this time I have heard some dandy stories and claims from health care professionals about compliance consultants - here are just a few recent ones:
A doctor called and asked if it were true that providers would get in trouble for not purchasing services from a speaker at a compliance seminar should federal investigators look at them, adding that the speaker told the seminar audience that he provides his list of seminar attendees to the FBI and that if one of the attendees were to be investigated by the Fed's their attendance would be used against them if they did not purchase his services.
In the more than 10 years of providing training for health care professionals I have never given or been asked by law enforcers for a list of attendees. But this speaker could in fact be giving his attendee list to the FBI - I don't know. With my investigator hat on, I can see how law enforcers could use this info for intelligence purposes but the info, in of itself, would be of minimal value unless there were suspicions that the health care professional was engaged in misconduct, and then it (attending the seminar) might be used in developed fraud cases with established evidence to support that the professional's violations of law were done purposefully - where the list might be of use to show the provider knew what they were doing was wrong and that they purposefully engaged in criminal conduct.
Another doctor, presently a compliance client, indicated that their previous compliance consultant used reported that by placing the (consultant's) compliance certificate on the wall in plain view for those coming into the clinic that if an investigator comes in and sees the certificate they will immediately turn around a leave because they will know the clinic is in compliance once they see his certificate.
Over the years I have heard of and seen people who wield a lot of power, but I have never heard of anyone in the compliance arena having that much power! And, I thought I had it going on.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street, Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Investigating Chiropractic Fraud
Health care fraud comes in many forms and unfortunately is not limited to any one health care discipline. Chiropractic is not immune from their members engaging in fraudulent activity that violates the laws and rules governing health care. With more than twenty years of experience, including investigating chiropractic fraud and assisting chiropractors on employing compliance programs, I offer the following bullets to refresh and/or develop fraud-fighters (providers, insurers, regulators & law enforcers) insight on chiropractic fraud.
Chiropractic Fraud, A growth industry...
Ignorance: Lack of knowledge and/or understanding of the laws and rules that govern health care.
Benchmark appropriateness of practice conduct based on what (they) perceive everyone else is doing.
Seminars: Increase income has very little to do with improving patient care. May provide information inconsistent with health care laws and rules. Trust but verify not followed here. Ads in chiropractic periodicals can assist on identifying current and developing chiropractic fraud trends.
Practice Builders: Instruct on methods and means to increase practice revenues and patient retention.
Aggressive marketing; increase services - especially tests. How to use the "CA" to build the practice; and may instruct on how to circumvent limitations on chiropractic.
Multiple Clinics: (Facilitator) Assists on opening clinics, instructs on what to do, how to bill, etc.
(Operator) Own/operate multiple clinics; scripts and protocols are the norm; high turnover rate
Both recruit extensively from Chiropractic Schools.
Vendors: (Manufacturers) Peddle devices with no specific code; provide a number of codes to get paid
(Billing Companies) may offer little or no oversight; may facilitate improper billings. (Testing) Increase revenues and patient retention; objectify the subjective; Mobile Labs - kickbacks.
Chiropractic Fraud, Types of Fraud
Marketing: Goal is to get as many people in the clinic as possible for conversion regardless of actual medical need; Telemarketing, mailers, screenings, dinner talks, scripted presentations, etc; promise "free services" to induce into clinic; Identify available insurance, or willingness to commit to payments - find condition - convert - treat - bill.
Services: Not rendered; not medically necessary; not recognized clinically and/or scientifically; substandard; Patients get same services on similar schedule - even when better (phases of care, ROF); Services based on available insurance or for legal reasons - not need (intake forms); Services for conditions not found in presenting complaints (aggressive marketing)
EXAMS: Free exams; Patterns; No exam performed; Extensive on subjective injuries; Does not address presenting complaints; Pre-determined (scripts, phases of care); Inadequate referrals
TESTS: Extension of exam, technical/professional; Free testing; Patterns; Extensive on subjective injuries (objectify); No relationship to patient complaints; Results not used in care and treatment; Use devices not recognized
TREATMENT: Free treatment (massage); Patterns; No relationship to presenting complaints; Provider services by non-providers; One-on-one services; Patients direct treatment, treat themselves; Medicare - CMT only; Non-covered provider (managed care); Multi-discipline practices (treating same)
SUPPLIES/REPORTS: Supplement/adjunct to treatment; Patterns; Supports, braces, TENS, etc.; Provide - Rent - Sell; No relationship to patient complaints; Administered at clinic as well as at home
Supplies/materials; Special reports; Educational services/supplies
Documentation: If it is not documented then it did not happen; Inadequate documentation to establish need, support rendered, who provided; Non-health care documents in the file; multiple patient files for same patient; Notes prepared to support payment - not health care rendered; prepared only when requested by payers; Notes more extensive for liability carriers, reports appear the same on all patients; Scheduling books, sign-in sheets, wand, computer generated notes, travel cards, forms, checklists, etc.
Coding: Follow the money! ICD-9, CPT-4, CMS-1500 (instructions); Goal is to bill certain amounts per patient visit; Quick codes - automatically bill; Report all services insurance covers (regardless of need); Use codes based on what paid - not what done; External billing companies
EXAM RED FLAGS: Free services; no ICD and CPT link; Patterns; Comprehensive and/or daily exams billed; No initial exam or re-exams billed; Modifier -25; Consultations; Extended visit codes; Multi-discipline practice (MD, DC exams, PT evals)
TEST RED FLAGS: Free services; ICD and CPT link; Patterns; Extensive on subjective
X-ray reading codes; Tests on visit after exam; substandard testing devices; Mobile Labs, Multi-discipline practice (DC x-rays billed under MD)
TREATMENT RED FLAGS: Free services; ICD and CPT link; Patterns; Subluxations only on Medicare; Time-based; Modifiers; No CMT billed (Manual Therapy); Place of service; Multi-discipline practices
SUPPLIES/REPORTS RED FLAGS: Free services; ICD and CPT link; Patterns; Excessive charges; TENS, Supplies; Educational supplies/services; Special Reports/Analysis; Multi-discipline practice
Collection Fraud: Insured's pay more for similar services than cash patients; Accept what insurance pays; forgo collection of deductibles, co-pays, etc.; Medicare beneficiaries often induced and may pay more for care (CMT) than other patients; Seek compensation for non-covered services reported as if covered (in name of covered provider); Attorney reductions, TOS, Financial hardships, pre-pay; External billing companies typically do not involve themselves with cash patients; Forms, checklists, EOB's, payer contracts, carrier manuals, practice acts
Health Care Fraud
Services not rendered: Billed exam following promised free exam; Daily exams; Services not documented; Services of one provider under another provider; CPT codes not reflective of what performed; Quick-codes; Multi-discipline practices; mobile labs; manufacturers; multiple clinics
Substandard/unnecessary services: Free exams and services (inducements); Treat conditions not identified in presenting complaints; Same services/similar schedule; Protocols/phases of care; Incomplete/inaccurate documentation; Not responsible what not paid by insurance; Provider services by non-providers; by patients; Multi-discipline practices; mobile labs; manufacturers; multiple clinics
Misrepresent nature of service provided: Exams (Comprehensive - Pattern - Daily); Diagnostic testing not used in care and treatment; Codes based on what paid, not what done; Upcoding, unbundling; Provider services by non-providers; One-on-one services not one-on-one; Improper use of modifiers; Medicare; Multi-discipline practices, mobile labs, manufacturers, multiple clinics
Misrepresent actual service provider: Provider services by non-providers; Services self-administered by patients; Services by one provider but billed under other (covered) provider; Multi-discipline practices; mobile labs; multiple clinics.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Chiropractic Fraud, A growth industry...
Ignorance: Lack of knowledge and/or understanding of the laws and rules that govern health care.
Benchmark appropriateness of practice conduct based on what (they) perceive everyone else is doing.
Seminars: Increase income has very little to do with improving patient care. May provide information inconsistent with health care laws and rules. Trust but verify not followed here. Ads in chiropractic periodicals can assist on identifying current and developing chiropractic fraud trends.
Practice Builders: Instruct on methods and means to increase practice revenues and patient retention.
Aggressive marketing; increase services - especially tests. How to use the "CA" to build the practice; and may instruct on how to circumvent limitations on chiropractic.
Multiple Clinics: (Facilitator) Assists on opening clinics, instructs on what to do, how to bill, etc.
(Operator) Own/operate multiple clinics; scripts and protocols are the norm; high turnover rate
Both recruit extensively from Chiropractic Schools.
Vendors: (Manufacturers) Peddle devices with no specific code; provide a number of codes to get paid
(Billing Companies) may offer little or no oversight; may facilitate improper billings. (Testing) Increase revenues and patient retention; objectify the subjective; Mobile Labs - kickbacks.
Chiropractic Fraud, Types of Fraud
Marketing: Goal is to get as many people in the clinic as possible for conversion regardless of actual medical need; Telemarketing, mailers, screenings, dinner talks, scripted presentations, etc; promise "free services" to induce into clinic; Identify available insurance, or willingness to commit to payments - find condition - convert - treat - bill.
Services: Not rendered; not medically necessary; not recognized clinically and/or scientifically; substandard; Patients get same services on similar schedule - even when better (phases of care, ROF); Services based on available insurance or for legal reasons - not need (intake forms); Services for conditions not found in presenting complaints (aggressive marketing)
EXAMS: Free exams; Patterns; No exam performed; Extensive on subjective injuries; Does not address presenting complaints; Pre-determined (scripts, phases of care); Inadequate referrals
TESTS: Extension of exam, technical/professional; Free testing; Patterns; Extensive on subjective injuries (objectify); No relationship to patient complaints; Results not used in care and treatment; Use devices not recognized
TREATMENT: Free treatment (massage); Patterns; No relationship to presenting complaints; Provider services by non-providers; One-on-one services; Patients direct treatment, treat themselves; Medicare - CMT only; Non-covered provider (managed care); Multi-discipline practices (treating same)
SUPPLIES/REPORTS: Supplement/adjunct to treatment; Patterns; Supports, braces, TENS, etc.; Provide - Rent - Sell; No relationship to patient complaints; Administered at clinic as well as at home
Supplies/materials; Special reports; Educational services/supplies
Documentation: If it is not documented then it did not happen; Inadequate documentation to establish need, support rendered, who provided; Non-health care documents in the file; multiple patient files for same patient; Notes prepared to support payment - not health care rendered; prepared only when requested by payers; Notes more extensive for liability carriers, reports appear the same on all patients; Scheduling books, sign-in sheets, wand, computer generated notes, travel cards, forms, checklists, etc.
Coding: Follow the money! ICD-9, CPT-4, CMS-1500 (instructions); Goal is to bill certain amounts per patient visit; Quick codes - automatically bill; Report all services insurance covers (regardless of need); Use codes based on what paid - not what done; External billing companies
EXAM RED FLAGS: Free services; no ICD and CPT link; Patterns; Comprehensive and/or daily exams billed; No initial exam or re-exams billed; Modifier -25; Consultations; Extended visit codes; Multi-discipline practice (MD, DC exams, PT evals)
TEST RED FLAGS: Free services; ICD and CPT link; Patterns; Extensive on subjective
X-ray reading codes; Tests on visit after exam; substandard testing devices; Mobile Labs, Multi-discipline practice (DC x-rays billed under MD)
TREATMENT RED FLAGS: Free services; ICD and CPT link; Patterns; Subluxations only on Medicare; Time-based; Modifiers; No CMT billed (Manual Therapy); Place of service; Multi-discipline practices
SUPPLIES/REPORTS RED FLAGS: Free services; ICD and CPT link; Patterns; Excessive charges; TENS, Supplies; Educational supplies/services; Special Reports/Analysis; Multi-discipline practice
Collection Fraud: Insured's pay more for similar services than cash patients; Accept what insurance pays; forgo collection of deductibles, co-pays, etc.; Medicare beneficiaries often induced and may pay more for care (CMT) than other patients; Seek compensation for non-covered services reported as if covered (in name of covered provider); Attorney reductions, TOS, Financial hardships, pre-pay; External billing companies typically do not involve themselves with cash patients; Forms, checklists, EOB's, payer contracts, carrier manuals, practice acts
Health Care Fraud
Services not rendered: Billed exam following promised free exam; Daily exams; Services not documented; Services of one provider under another provider; CPT codes not reflective of what performed; Quick-codes; Multi-discipline practices; mobile labs; manufacturers; multiple clinics
Substandard/unnecessary services: Free exams and services (inducements); Treat conditions not identified in presenting complaints; Same services/similar schedule; Protocols/phases of care; Incomplete/inaccurate documentation; Not responsible what not paid by insurance; Provider services by non-providers; by patients; Multi-discipline practices; mobile labs; manufacturers; multiple clinics
Misrepresent nature of service provided: Exams (Comprehensive - Pattern - Daily); Diagnostic testing not used in care and treatment; Codes based on what paid, not what done; Upcoding, unbundling; Provider services by non-providers; One-on-one services not one-on-one; Improper use of modifiers; Medicare; Multi-discipline practices, mobile labs, manufacturers, multiple clinics
Misrepresent actual service provider: Provider services by non-providers; Services self-administered by patients; Services by one provider but billed under other (covered) provider; Multi-discipline practices; mobile labs; multiple clinics.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
The Next Generation of Multi-Discipline Practice Fraud
The evolution of multi-discipline fraud has included the advent of practices created on the advice of practice building consultants as a means of avoiding or eliminating limited chiropractic insurance coverage by associating an MD. However, this type of practice has lost its popularity of late due to increased scrutiny and investigative interests on the part of third party payers, state regulators and law enforcers. The next generation of multi-discipline practice fraud no longer necessitates the involvement of an MD, just a physical therapist willing to join the practice to expand reimbursement potentials and avoid coverage limitations.
One must be careful not to use a broad-brush to paint all multi-discipline practices with fraud. Most providers have patient care in mind and not only the financial bottom-line, where most use due care to ensure that their practice operates in compliance with the laws, rules and regulations governing health care.
It could be a next generation multi-discipline practice fraud if...
• The practice was created to maximize reimbursements for health care services by (1) reporting services similar in nature rendered by providers of differing disciplines; (2) avoiding limited insurance coverage of one provider by having a provider of a different (covered) discipline render the health care; and/or (3) allowing the non-covered provider to bill for their rendered services under the license of the covered provider.
• The practice has differing practice names and tax identification numbers, based on the discipline rendering care, to avoid detection that a provider - with limited available insurance, is involved in the control and direction of health care services.
• The practice sees a high volume of patients, typically obtained as the result of extensive marketing of free health care services, where patients are told that their health care won't cost them anything, that insurance will pay. Patients are not informed on amounts billed, where the practice will forgo collection of deductible, co-payment and/or co-insurance amounts.
• The practice provides services based on available insurance and not the medical need of the patient. The same treatment on a similar schedule is provided to all patients, where the treatment remains the same, including multiple modalities, even when the patient is better.
• The practice fails to properly document referrals from the physician to the physical therapists and the physician's review of the physical therapist's work; and/or documents physician referrals to the physical therapist ordering specific services that is not followed by the physical therapist.
• The practice reports multiple provider encounters with the patient on the same day, where the patient reportedly sees providers of differing disciplines for the administration of health care services that could be administered by one provider.
• The practice reports extensive physician examinations, physical therapy evaluations which are not adequately documented in the patient's clinical record to have been performed - including treatment plans to describe the type, amount, frequency/duration of services to patients that indicates the diagnosis, anticipated goals, and specific functional goals with an estimate of when they will be reached.
• The practice reports extensive electro-diagnostic testing (especially range of motion and muscle testing), typically the day after an exam/eval, with little or no documentation as to why, and how used in the care and treatment of the patient.
• The practice reports services that are not completely and accurately documented in the patient's clinical record to account for the specific activity performed, the body area treated, the intensity and duration of the service, as well as the time spent rendering time-based services and procedures.
• The practice delegates the administration of services to unlicensed staff, despite requirements that the services be performed by a (licensed) provider in direct one-on-one contact with the patient.
• The practice reports extensive time-based services with minimal qualified (licensed) providers on staff that were actually administered by unlicensed staff, and/or provided for less than the required 15 minute increment without use of appropriate modifier.
• The practice reports services rendered by one provider under another disciplined provider that would otherwise be non-covered.
• The practice reports health care service combinations rendered to the same body area during the same patient encounter under differing disciplined providers that would otherwise be non-covered.
• The practice reports services not accurately reflective of the actual service/procedure rendered.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at
Chiropractic Compliance Consultants, Inc.,
18065 238th Street
Tonganoxie, Kansas 66086
913-369-9000
http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
One must be careful not to use a broad-brush to paint all multi-discipline practices with fraud. Most providers have patient care in mind and not only the financial bottom-line, where most use due care to ensure that their practice operates in compliance with the laws, rules and regulations governing health care.
It could be a next generation multi-discipline practice fraud if...
• The practice was created to maximize reimbursements for health care services by (1) reporting services similar in nature rendered by providers of differing disciplines; (2) avoiding limited insurance coverage of one provider by having a provider of a different (covered) discipline render the health care; and/or (3) allowing the non-covered provider to bill for their rendered services under the license of the covered provider.
• The practice has differing practice names and tax identification numbers, based on the discipline rendering care, to avoid detection that a provider - with limited available insurance, is involved in the control and direction of health care services.
• The practice sees a high volume of patients, typically obtained as the result of extensive marketing of free health care services, where patients are told that their health care won't cost them anything, that insurance will pay. Patients are not informed on amounts billed, where the practice will forgo collection of deductible, co-payment and/or co-insurance amounts.
• The practice provides services based on available insurance and not the medical need of the patient. The same treatment on a similar schedule is provided to all patients, where the treatment remains the same, including multiple modalities, even when the patient is better.
• The practice fails to properly document referrals from the physician to the physical therapists and the physician's review of the physical therapist's work; and/or documents physician referrals to the physical therapist ordering specific services that is not followed by the physical therapist.
• The practice reports multiple provider encounters with the patient on the same day, where the patient reportedly sees providers of differing disciplines for the administration of health care services that could be administered by one provider.
• The practice reports extensive physician examinations, physical therapy evaluations which are not adequately documented in the patient's clinical record to have been performed - including treatment plans to describe the type, amount, frequency/duration of services to patients that indicates the diagnosis, anticipated goals, and specific functional goals with an estimate of when they will be reached.
• The practice reports extensive electro-diagnostic testing (especially range of motion and muscle testing), typically the day after an exam/eval, with little or no documentation as to why, and how used in the care and treatment of the patient.
• The practice reports services that are not completely and accurately documented in the patient's clinical record to account for the specific activity performed, the body area treated, the intensity and duration of the service, as well as the time spent rendering time-based services and procedures.
• The practice delegates the administration of services to unlicensed staff, despite requirements that the services be performed by a (licensed) provider in direct one-on-one contact with the patient.
• The practice reports extensive time-based services with minimal qualified (licensed) providers on staff that were actually administered by unlicensed staff, and/or provided for less than the required 15 minute increment without use of appropriate modifier.
• The practice reports services rendered by one provider under another disciplined provider that would otherwise be non-covered.
• The practice reports health care service combinations rendered to the same body area during the same patient encounter under differing disciplined providers that would otherwise be non-covered.
• The practice reports services not accurately reflective of the actual service/procedure rendered.
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at
Chiropractic Compliance Consultants, Inc.,
18065 238th Street
Tonganoxie, Kansas 66086
913-369-9000
http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
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:
•DOCUMENTATION-was the services documented as medically necessary, and completely and accurately documented in the patient's health care record?
•REGULATORY 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?
•THIRD 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?
•CODING-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 FRAUD
Problem (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?
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
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:
•DOCUMENTATION-was the services documented as medically necessary, and completely and accurately documented in the patient's health care record?
•REGULATORY 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?
•THIRD 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?
•CODING-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 FRAUD
Problem (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?
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Therapeutic Procedures - Explode Your Practice
One of the more potentially volatile risk areas for health care practitioners today is the delegation of therapeutic procedures to unlicensed assistants, and billing for those procedures as though the practitioner personally provided the procedures. This practice activity is particularly prevalent and ever-growing in chiropractic!
Some practice consultants - with promises of increased income, coach chiropractors to integrate low-tech rehab and protocols into their practices. Chiropractors are advised that it is legally permissible for unlicensed assistants (e.g., chiropractic assistants) to perform the therapeutic procedures on patients that are billed (per "incident-to") as if personally performed by the chiropractor, who at the same time, is providing services to other patients who are billed for the chiropractor's services during the same time frames as the therapeutic procedures.
Does the regulatory board allow for delegation of therapeutic procedures to unlicensed staff?
Individual state health care regulatory boards establish their own state's administrative practice standards for licensees for the purpose of protecting the public from conduct that does not conform to their state's accepted standards of conduct. Such administrative regulations almost always include standards relating to the delegation of services to persons other than the licensed provider. In many states, chiropractic boards do not allow their licensees to delegate therapeutic procedures to unlicensed staff, and, as such it would be inappropriate in any and all circumstances for the licensees to engage in this conduct!
However, some boards opine that licensees (e.g., chiropractors) can delegate therapeutic procedures to qualified and properly trained unlicensed staff (e.g., chiropractic assistants) acting under a licensee's supervision consistent with the health and welfare of a patient so as to encourage the more effective use of the skills of licensees. It would appear prudent for chiropractors to gain clarification from respective regulatory agencies regarding the following:
What are the standards that must be met by chiropractors to ensure their unlicensed staff are "qualified and properly trained"?
What level of supervision (general, direct or personnel) is required of the chiropractor relative to unlicensed staff directing therapeutic procedures?
What is meant by "consistent with the health and welfare of a patient so as to encourage the more effective use of the skills of licensees"?
How should the therapeutic procedures (supervised) by unlicensed staff be documented in the patient's clinical record?
How should the therapeutic procedures be reported to payers - especially those following Medicare standards, to avoid potential allegations of misconduct?
Is reporting therapeutic procedure codes for supervised procedures consistent with CPT?
Therapeutic procedure codes (97110-97546) identify the application of clinical skills and/or services that attempt to improve function that requires the physician or therapist to have direct (one-on-one) contact with the patient. These procedure codes do not indicate "supervised" services and to report them to payers in such a manner could result in allegations of misconduct. Consequently, it is imperative for the practitioner (e.g., chiropractor) to obtain prior approval for this billing practice from ALL involved payers notwithstanding the fact that this type of practice activity has previously been found to be consistent with state regulatory standards on delegation. The purpose of seeking the payer's approval is not to enable the payer to make determinations on what practices are legal and what practices are not; rather, it is to protect the individual provider from a payer's unilateral referral of the provider billing practices to law enforcement authorities who may have a differing interpretation of the acceptable standards of delegation that the provider's state regulatory board.
Current Procedural Terminology (CPT) is a listing of (a) descriptive terms and (b) identifying codes. The foregoing is used to report medical services and procedures, as well as to provide a uniform language that accurately describes medical, surgical, and diagnostic services. The use of CPT provides an effective means of reliable nationwide communication among providers, patients, and payers.
The listing of a service or procedure and its code number in a specific section is not restricted to any specific specialty group. Any procedure or service in any section may be used to designate services rendered by any qualified physician or other qualified health care professional. CPT indicates that the terms -"Physician or Therapist" and "Provider" as identified in CPT are interchangeable to refer to someone licensed to perform health care services.
Select the name of the procedure or service that accurately identifies the service performed that is adequately documented in the medical record. Do not select a CPT code that merely approximates the service provided, and that if no such procedure or service exists then report the service using the appropriate unlisted procedure or service.
Suggestions concerning introduction of new procedures, or the coding, deleting, or revising of procedures contained in CPT should be made by contacting the CPT Editorial Research & Development.
The Final Rule for transactions and code sets as part of the Health Insurance Portability and Accountability Act (HIPAA) identifies CPT codes and modifiers as the national standard for health care plans and providers to electronically transmit: Physician services; physical and occupational therapy services; radiological procedures; clinical laboratory tests; other medical diagnostic procedures; hearing and vision services; and transportation services including ambulance.
Does the involved payer reimburse for supervised therapeutic procedures?
Payers often set their own standards for reimbursement of health care services and determine what will be paid, who will be paid, and how much will be paid. Standards may vary from payer to payer, and may differ from those standards established by the provider's own regulatory licensing board. Accordingly, it is the responsibility of all practitioners (e.g., chiropractors) to be familiar with both the payer's billing/coding and their state board's standards and seek to abide by those standards that impose the stricter requirements when seeking reimbursement! By adopting a policy of compliance with the stricter standard the provider will always ensure that he/she is protected from claims of improper billing practices.
Medicare, and other payers following Medicare standards, indicates that therapeutic procedures supervised by (unqualified) unlicensed staff are not reimbursable! Payers with such standards do not pay for provider services, at provider rates, when such services are administered by non-providers. Further, these payers do not maintain that practitioners can not delegate therapeutic procedures to unlicensed assistants but are asserting that such services are not covered and, therefore, they are not reimbursable - BILL THE PATIENT! Medicare Benefits Policy Manual, Chapter 15, Sections 220 and 230 specifies:
Therapeutic procedures are medically necessary only when they require the professional skills of a qualified practitioner, are designed to address specific needs of the patient, and are part of an active treatment plan intended to achieve a specific goal.
Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service.
Providers can not bill and seek payment for one-on-one codes (e.g., therapeutic procedures) administered at the same time as other procedures were rendered to the patient, or to other patients.
A physician may not delegate physical therapy services (e.g., therapeutic procedures) to unlicensed persons and report them as "incident-to" services unless that person has the education and clinical experience equivalent to a physical therapist.
Incident-to a physician's professional services are defined (Benefits Policy Manual, Chapter 15, Section 60) as services or supplies furnished by auxiliary personnel as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness that are billed to Part B by the physician as if they personally provided them.
Some within chiropractic have differing opinions as to the appropriateness of the delegation and billing of therapeutic procedures. Illustrative of this is the following written opinion of a chiropractor to whom a colleague was referred subsequent to requesting assistance from a State Chiropractic Association regarding the issue discussed herein:
The auditor is confused, to say the least. As a doctor, you can delegate to whomever you wish to perform those [therapeutic procedure] services. You simply must be in the building at the time services are rendered to supervise [sic]. You do not have to perform the treatment yourself, nor do you have to stand over them and watch. This auditor may be confused with what some insurance companies are pushing for and have proposed, i.e., they require the doctor to do it. However, as far as I know, no insurance company has any policy in place to prohibit you from delegating to staff. As far as statute goes in Xx, if an insurance company did write that into their policy, we would have to go to the Xx with complaint. The P.T.'s would love to have those rules in place as well. Short answer is the auditor is wrong. Maybe some other state he/she is familiar with has that as a rule. Not here though.
The bottom-line is that due-care and good judgment must be exercised by chiropractors in this risk area, as missteps could result in administrative, civil and/or criminal exposure. A few years ago chiropractors, similarly instructed on use of "incident-to" to increase income, billed for their rendered services under the license of an associated medical doctor in MD/DC practices so as to avoid limited chiropractic (insurance) coverage. Several of these doctors, including a highly prominent chiropractic consultant who advised them on the use of "incident to" billing, are now serving federal prison sentences. Many chiropractors have learned the hard way that "incident-to" does not allow for the misrepresentation of the actual service provider to facilitate reimbursement for services that would otherwise be non-covered.
ORIGINALLY PUBLISHED: "Zalma Newsletter", July 2007.
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Some practice consultants - with promises of increased income, coach chiropractors to integrate low-tech rehab and protocols into their practices. Chiropractors are advised that it is legally permissible for unlicensed assistants (e.g., chiropractic assistants) to perform the therapeutic procedures on patients that are billed (per "incident-to") as if personally performed by the chiropractor, who at the same time, is providing services to other patients who are billed for the chiropractor's services during the same time frames as the therapeutic procedures.
Does the regulatory board allow for delegation of therapeutic procedures to unlicensed staff?
Individual state health care regulatory boards establish their own state's administrative practice standards for licensees for the purpose of protecting the public from conduct that does not conform to their state's accepted standards of conduct. Such administrative regulations almost always include standards relating to the delegation of services to persons other than the licensed provider. In many states, chiropractic boards do not allow their licensees to delegate therapeutic procedures to unlicensed staff, and, as such it would be inappropriate in any and all circumstances for the licensees to engage in this conduct!
However, some boards opine that licensees (e.g., chiropractors) can delegate therapeutic procedures to qualified and properly trained unlicensed staff (e.g., chiropractic assistants) acting under a licensee's supervision consistent with the health and welfare of a patient so as to encourage the more effective use of the skills of licensees. It would appear prudent for chiropractors to gain clarification from respective regulatory agencies regarding the following:
What are the standards that must be met by chiropractors to ensure their unlicensed staff are "qualified and properly trained"?
What level of supervision (general, direct or personnel) is required of the chiropractor relative to unlicensed staff directing therapeutic procedures?
What is meant by "consistent with the health and welfare of a patient so as to encourage the more effective use of the skills of licensees"?
How should the therapeutic procedures (supervised) by unlicensed staff be documented in the patient's clinical record?
How should the therapeutic procedures be reported to payers - especially those following Medicare standards, to avoid potential allegations of misconduct?
Is reporting therapeutic procedure codes for supervised procedures consistent with CPT?
Therapeutic procedure codes (97110-97546) identify the application of clinical skills and/or services that attempt to improve function that requires the physician or therapist to have direct (one-on-one) contact with the patient. These procedure codes do not indicate "supervised" services and to report them to payers in such a manner could result in allegations of misconduct. Consequently, it is imperative for the practitioner (e.g., chiropractor) to obtain prior approval for this billing practice from ALL involved payers notwithstanding the fact that this type of practice activity has previously been found to be consistent with state regulatory standards on delegation. The purpose of seeking the payer's approval is not to enable the payer to make determinations on what practices are legal and what practices are not; rather, it is to protect the individual provider from a payer's unilateral referral of the provider billing practices to law enforcement authorities who may have a differing interpretation of the acceptable standards of delegation that the provider's state regulatory board.
Current Procedural Terminology (CPT) is a listing of (a) descriptive terms and (b) identifying codes. The foregoing is used to report medical services and procedures, as well as to provide a uniform language that accurately describes medical, surgical, and diagnostic services. The use of CPT provides an effective means of reliable nationwide communication among providers, patients, and payers.
The listing of a service or procedure and its code number in a specific section is not restricted to any specific specialty group. Any procedure or service in any section may be used to designate services rendered by any qualified physician or other qualified health care professional. CPT indicates that the terms -"Physician or Therapist" and "Provider" as identified in CPT are interchangeable to refer to someone licensed to perform health care services.
Select the name of the procedure or service that accurately identifies the service performed that is adequately documented in the medical record. Do not select a CPT code that merely approximates the service provided, and that if no such procedure or service exists then report the service using the appropriate unlisted procedure or service.
Suggestions concerning introduction of new procedures, or the coding, deleting, or revising of procedures contained in CPT should be made by contacting the CPT Editorial Research & Development.
The Final Rule for transactions and code sets as part of the Health Insurance Portability and Accountability Act (HIPAA) identifies CPT codes and modifiers as the national standard for health care plans and providers to electronically transmit: Physician services; physical and occupational therapy services; radiological procedures; clinical laboratory tests; other medical diagnostic procedures; hearing and vision services; and transportation services including ambulance.
Does the involved payer reimburse for supervised therapeutic procedures?
Payers often set their own standards for reimbursement of health care services and determine what will be paid, who will be paid, and how much will be paid. Standards may vary from payer to payer, and may differ from those standards established by the provider's own regulatory licensing board. Accordingly, it is the responsibility of all practitioners (e.g., chiropractors) to be familiar with both the payer's billing/coding and their state board's standards and seek to abide by those standards that impose the stricter requirements when seeking reimbursement! By adopting a policy of compliance with the stricter standard the provider will always ensure that he/she is protected from claims of improper billing practices.
Medicare, and other payers following Medicare standards, indicates that therapeutic procedures supervised by (unqualified) unlicensed staff are not reimbursable! Payers with such standards do not pay for provider services, at provider rates, when such services are administered by non-providers. Further, these payers do not maintain that practitioners can not delegate therapeutic procedures to unlicensed assistants but are asserting that such services are not covered and, therefore, they are not reimbursable - BILL THE PATIENT! Medicare Benefits Policy Manual, Chapter 15, Sections 220 and 230 specifies:
Therapeutic procedures are medically necessary only when they require the professional skills of a qualified practitioner, are designed to address specific needs of the patient, and are part of an active treatment plan intended to achieve a specific goal.
Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service.
Providers can not bill and seek payment for one-on-one codes (e.g., therapeutic procedures) administered at the same time as other procedures were rendered to the patient, or to other patients.
A physician may not delegate physical therapy services (e.g., therapeutic procedures) to unlicensed persons and report them as "incident-to" services unless that person has the education and clinical experience equivalent to a physical therapist.
Incident-to a physician's professional services are defined (Benefits Policy Manual, Chapter 15, Section 60) as services or supplies furnished by auxiliary personnel as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness that are billed to Part B by the physician as if they personally provided them.
Some within chiropractic have differing opinions as to the appropriateness of the delegation and billing of therapeutic procedures. Illustrative of this is the following written opinion of a chiropractor to whom a colleague was referred subsequent to requesting assistance from a State Chiropractic Association regarding the issue discussed herein:
The auditor is confused, to say the least. As a doctor, you can delegate to whomever you wish to perform those [therapeutic procedure] services. You simply must be in the building at the time services are rendered to supervise [sic]. You do not have to perform the treatment yourself, nor do you have to stand over them and watch. This auditor may be confused with what some insurance companies are pushing for and have proposed, i.e., they require the doctor to do it. However, as far as I know, no insurance company has any policy in place to prohibit you from delegating to staff. As far as statute goes in Xx, if an insurance company did write that into their policy, we would have to go to the Xx with complaint. The P.T.'s would love to have those rules in place as well. Short answer is the auditor is wrong. Maybe some other state he/she is familiar with has that as a rule. Not here though.
The bottom-line is that due-care and good judgment must be exercised by chiropractors in this risk area, as missteps could result in administrative, civil and/or criminal exposure. A few years ago chiropractors, similarly instructed on use of "incident-to" to increase income, billed for their rendered services under the license of an associated medical doctor in MD/DC practices so as to avoid limited chiropractic (insurance) coverage. Several of these doctors, including a highly prominent chiropractic consultant who advised them on the use of "incident to" billing, are now serving federal prison sentences. Many chiropractors have learned the hard way that "incident-to" does not allow for the misrepresentation of the actual service provider to facilitate reimbursement for services that would otherwise be non-covered.
ORIGINALLY PUBLISHED: "Zalma Newsletter", July 2007.
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Health Care Fraud - The Costly Deception?
For years significant resources have reportedly been directed towards combating health care fraud by insurers, regulators, law enforcers and legislators. Yet, despite these reported efforts, it would appear, based on the annual estimates, the problem continues to grow and flourish.
Could this indicate that health care fraud is at epidemic proportions and can't be stopped as our health care system is infested with health care providers who will stop at nothing to make a buck? I think not.
My experience, over two decades of working with insurers, law enforcers, regulators and health care providers, suggests that most health care providers are honest, ethical and strive to do the right thing!
Additionally, my experience has provided me with the opportunity to see the fraud problem from both sides, that of enforcement and the provider. When viewed from both perspectives, it is readily apparent that our health care fraud problem is caused by a number of factors, including:
1. Inadequate education for health care providers relative to coding and payer standards.
2. Deviant providers.
3. Inadequate training for claims handlers and claims investigators on coding and provider standards.
4. Inept claims handling and claims investigations by insurers prior to paying claims.
5. Lack of communication from insurer to provider on what is required.
6. Paucity of reliable training for law enforcers regarding the investigation of health care fraud - from identification to prosecution.
7. Tag-a-long investigators looking for organizational stats resulting in the inefficient use of law enforcement resources.
8. Lack of interest or commitment by prosecutors - big cases big problems, little cases little problems.
9. Lack of accountability for all segments of the health care delivery system - provider, payer, regulator and enforcer.
Insurers, the main reporter and victim of the fraud, indicate that all policyholders pay for the fraud in the form of higher premiums. According to the National Insurance Crime Bureau, the average American household will pay $200 more every year in premiums to pay for the fraud.
Insurers are very aggressive in reporting how costly the problem is, revealing estimates of double-digit percentages of claims submitted that are fraudulent, and billions of dollars lost each year due to fraud. These reports and estimates weigh heavily in the minds of state insurance regulators when they allow insurers to raise premiums.
Basically, what insurers and others refer to when they reveal their estimates on the frequency and costs of health care provider fraud is the billing for services not rendered, billing for services that are substandard and/or unnecessary, billing for services that misrepresent the nature of the service provided, billing for services that misrepresent the actual service provider...
The sweeping nature of the attention health care providers are getting, even those not engaged in fraudulent activity, by insurers in post-payment audits is unprecedented, and may take away from the ability of our health care providers to do what they do best - make people better! It is unfortunate that today, health care providers may spend more time documenting and defending their services to a multitude of sources, to include insurers, regulators and law enforcers, then they do providing health care services to patients.
Health care fraud is a crime that should be dealt with swiftly, responsibly and severely! But, health care fraud should not be used as a vehicle for one to prosper at another's expense. Insurers are in the business of making money, and they are doing just that, making money - making a lot of money! This money comes from premiums collected on the sale of policies to consumers seeking protection from future (unknown) losses.
Many insurers are in a position to limit their potential health care claims exposure as they possess the ability to tell insureds' what doctor they can see, what treatment services they can get, and how much will be paid for the services.
Further, insurers may capriciously limit payment on health care claims denying health care services reported by health care providers, asserting the services were illegitimate, claiming the services were fraudulent. Many insurers conduct claims-evaluations, reportedly for the purpose of determining if the health care services rendered by the provider were usual, customary and/or reasonable (UCR). Consider that by definition, "fraud is the knowing and willful deception or misrepresentation of the facts with intent to receive an unauthorized payment."
Wouldn't such an evaluation be considered a fraud evaluation? It is purportedly done for the purpose of determining if the health care provider misrepresented the nature of the services provided and reported, i.e. fraud.
Unfortunately, the UCR evaluation seems to have little to do with actual fraud fighting, but everything to do with cost containment and the bottom line for insurers. These evaluations typically do not identify that the health care provider did not provide the reported services, but instead report subjective opinions of consultant providers who usually do not even see the patient. In many cases, insurers may successfully reduce the health care provider's billings using UCR evaluations - not because the evaluations were accurate, but because the health care provider did not have the knowledge or necessary resources to fight back.
The effectiveness of these evaluations as a means to combat fraud is questionable, and may be non-existent.
Check with your state insurance regulators and health care boards to determine if insurers refer their UCR evaluations to them for fraud investigations, and, if so, ask them how many. Ask your local law enforcers how many cases they investigate or prosecute that were based on UCR evaluations.
Further, ask your insurer what percentages of their estimated losses due to health care fraud include UCR evaluations. And, ask your insurer why, with their duty and ability to examine all claims, are they unable to do a better job in not paying fraudulent claims.
Interestingly, since the late 1980's, health care providers have had a standard coding system. This system, known as Current Procedural Terminology (CPT), is used by providers to report and bill for health care services rendered to patients.
CPT was promulgated by the American Medical Association (AMA) so that all health care providers, regardless of discipline, could accurately report their services and be compensated for services rendered.
Although CPT has been around for decades, there are no standards of education and training required of health care providers for the proper use of the codes, or insurers for what the codes mean. This may lead to a systematic problem in our health care system, as an unnecessary adversarial system is created between our health care providers and health care payers based on an 'attack and defense' of billing codes and treatment records.
Both are looking at the codes, viz., one for the purpose of reporting services to seek compensation, and the other for determining what they will pay.
It should be evident, from the annual reports, if they are accurate, that our health care fraud problem will not be solved solely by amassing a large amount of resources to attack the problem, creating consortiums to share information and research the problem, or with the introduction of additional laws or regulations from politicians stumping for re-election. The investigation of health care fraud for the purpose of prosecuting the offenders is needed. But, also needed is a mandatory educational process for our providers, insurers and investigators on combating health care fraud.
The health care fraud problem is too complex to be battled by the few. Health care fraud is a problem that demands a greater participation by the principals of our health care system, so as to increase the likelihood that our successes in combating this costly problem will be enhanced, identifiable and verifiable.
Health care fraud is a problem - just read the news, but it is a problem that can and must be successfully addressed. This will only happen once our fraud-fighting team is completely accountable and includes the active participation of health care providers.
There is no stronger voice against health care fraud then that of honest and ethical health care providers - who, by the way are also insurance and health care consumers and part of the premium paying public. Most health care providers do not engage in fraud and would like to see those who do be stopped and put out of business. However, the current fraud fighting arena has health care providers - even the honest and law-abiding ones, pitted against insurers and others.
Health care providers who are not engaged in fraudulent activity must endure aggressive and invasive encounters with insurers to get paid for legitimate services provided. This process has a counterproductive effect on our overall success in combating health care fraud.
Health care providers who are not engaged in fraudulent activity may possess information and knowledge that would be useful in assisting health care fraud fighters. These providers could potentially assist at the street-level on the identification of health care providers engaged in fraud.
Furthermore, health care providers who are not engaged in fraudulent activity may assist fraud fighters with establishing the evidence to support prosecutions of the fraud. However, with the current adversarial system, health care providers who are not engaged in fraudulent activity may have neither the opportunity nor desire to assist fraud fighters as they are fighting payers for their mere financial existence.
Maybe it is time the various health care disciplines and health care provider associations formed an alliance to be the provider's action arm to work closely with law enforcers in attacking insurance and health care fraud, just as the insurance industry purports to do. And, just maybe, with such an alliance, we would actually see a drop in the annual estimates of the costs attributed to health care fraud - currently they range, depending on the source, from $20 to $160 Billion.
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Could this indicate that health care fraud is at epidemic proportions and can't be stopped as our health care system is infested with health care providers who will stop at nothing to make a buck? I think not.
My experience, over two decades of working with insurers, law enforcers, regulators and health care providers, suggests that most health care providers are honest, ethical and strive to do the right thing!
Additionally, my experience has provided me with the opportunity to see the fraud problem from both sides, that of enforcement and the provider. When viewed from both perspectives, it is readily apparent that our health care fraud problem is caused by a number of factors, including:
1. Inadequate education for health care providers relative to coding and payer standards.
2. Deviant providers.
3. Inadequate training for claims handlers and claims investigators on coding and provider standards.
4. Inept claims handling and claims investigations by insurers prior to paying claims.
5. Lack of communication from insurer to provider on what is required.
6. Paucity of reliable training for law enforcers regarding the investigation of health care fraud - from identification to prosecution.
7. Tag-a-long investigators looking for organizational stats resulting in the inefficient use of law enforcement resources.
8. Lack of interest or commitment by prosecutors - big cases big problems, little cases little problems.
9. Lack of accountability for all segments of the health care delivery system - provider, payer, regulator and enforcer.
Insurers, the main reporter and victim of the fraud, indicate that all policyholders pay for the fraud in the form of higher premiums. According to the National Insurance Crime Bureau, the average American household will pay $200 more every year in premiums to pay for the fraud.
Insurers are very aggressive in reporting how costly the problem is, revealing estimates of double-digit percentages of claims submitted that are fraudulent, and billions of dollars lost each year due to fraud. These reports and estimates weigh heavily in the minds of state insurance regulators when they allow insurers to raise premiums.
Basically, what insurers and others refer to when they reveal their estimates on the frequency and costs of health care provider fraud is the billing for services not rendered, billing for services that are substandard and/or unnecessary, billing for services that misrepresent the nature of the service provided, billing for services that misrepresent the actual service provider...
The sweeping nature of the attention health care providers are getting, even those not engaged in fraudulent activity, by insurers in post-payment audits is unprecedented, and may take away from the ability of our health care providers to do what they do best - make people better! It is unfortunate that today, health care providers may spend more time documenting and defending their services to a multitude of sources, to include insurers, regulators and law enforcers, then they do providing health care services to patients.
Health care fraud is a crime that should be dealt with swiftly, responsibly and severely! But, health care fraud should not be used as a vehicle for one to prosper at another's expense. Insurers are in the business of making money, and they are doing just that, making money - making a lot of money! This money comes from premiums collected on the sale of policies to consumers seeking protection from future (unknown) losses.
Many insurers are in a position to limit their potential health care claims exposure as they possess the ability to tell insureds' what doctor they can see, what treatment services they can get, and how much will be paid for the services.
Further, insurers may capriciously limit payment on health care claims denying health care services reported by health care providers, asserting the services were illegitimate, claiming the services were fraudulent. Many insurers conduct claims-evaluations, reportedly for the purpose of determining if the health care services rendered by the provider were usual, customary and/or reasonable (UCR). Consider that by definition, "fraud is the knowing and willful deception or misrepresentation of the facts with intent to receive an unauthorized payment."
Wouldn't such an evaluation be considered a fraud evaluation? It is purportedly done for the purpose of determining if the health care provider misrepresented the nature of the services provided and reported, i.e. fraud.
Unfortunately, the UCR evaluation seems to have little to do with actual fraud fighting, but everything to do with cost containment and the bottom line for insurers. These evaluations typically do not identify that the health care provider did not provide the reported services, but instead report subjective opinions of consultant providers who usually do not even see the patient. In many cases, insurers may successfully reduce the health care provider's billings using UCR evaluations - not because the evaluations were accurate, but because the health care provider did not have the knowledge or necessary resources to fight back.
The effectiveness of these evaluations as a means to combat fraud is questionable, and may be non-existent.
Check with your state insurance regulators and health care boards to determine if insurers refer their UCR evaluations to them for fraud investigations, and, if so, ask them how many. Ask your local law enforcers how many cases they investigate or prosecute that were based on UCR evaluations.
Further, ask your insurer what percentages of their estimated losses due to health care fraud include UCR evaluations. And, ask your insurer why, with their duty and ability to examine all claims, are they unable to do a better job in not paying fraudulent claims.
Interestingly, since the late 1980's, health care providers have had a standard coding system. This system, known as Current Procedural Terminology (CPT), is used by providers to report and bill for health care services rendered to patients.
CPT was promulgated by the American Medical Association (AMA) so that all health care providers, regardless of discipline, could accurately report their services and be compensated for services rendered.
Although CPT has been around for decades, there are no standards of education and training required of health care providers for the proper use of the codes, or insurers for what the codes mean. This may lead to a systematic problem in our health care system, as an unnecessary adversarial system is created between our health care providers and health care payers based on an 'attack and defense' of billing codes and treatment records.
Both are looking at the codes, viz., one for the purpose of reporting services to seek compensation, and the other for determining what they will pay.
It should be evident, from the annual reports, if they are accurate, that our health care fraud problem will not be solved solely by amassing a large amount of resources to attack the problem, creating consortiums to share information and research the problem, or with the introduction of additional laws or regulations from politicians stumping for re-election. The investigation of health care fraud for the purpose of prosecuting the offenders is needed. But, also needed is a mandatory educational process for our providers, insurers and investigators on combating health care fraud.
The health care fraud problem is too complex to be battled by the few. Health care fraud is a problem that demands a greater participation by the principals of our health care system, so as to increase the likelihood that our successes in combating this costly problem will be enhanced, identifiable and verifiable.
Health care fraud is a problem - just read the news, but it is a problem that can and must be successfully addressed. This will only happen once our fraud-fighting team is completely accountable and includes the active participation of health care providers.
There is no stronger voice against health care fraud then that of honest and ethical health care providers - who, by the way are also insurance and health care consumers and part of the premium paying public. Most health care providers do not engage in fraud and would like to see those who do be stopped and put out of business. However, the current fraud fighting arena has health care providers - even the honest and law-abiding ones, pitted against insurers and others.
Health care providers who are not engaged in fraudulent activity must endure aggressive and invasive encounters with insurers to get paid for legitimate services provided. This process has a counterproductive effect on our overall success in combating health care fraud.
Health care providers who are not engaged in fraudulent activity may possess information and knowledge that would be useful in assisting health care fraud fighters. These providers could potentially assist at the street-level on the identification of health care providers engaged in fraud.
Furthermore, health care providers who are not engaged in fraudulent activity may assist fraud fighters with establishing the evidence to support prosecutions of the fraud. However, with the current adversarial system, health care providers who are not engaged in fraudulent activity may have neither the opportunity nor desire to assist fraud fighters as they are fighting payers for their mere financial existence.
Maybe it is time the various health care disciplines and health care provider associations formed an alliance to be the provider's action arm to work closely with law enforcers in attacking insurance and health care fraud, just as the insurance industry purports to do. And, just maybe, with such an alliance, we would actually see a drop in the annual estimates of the costs attributed to health care fraud - currently they range, depending on the source, from $20 to $160 Billion.
Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chripractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
9 Biggest Mistakes Health Care Providers Make That Result in Surprise Visits From Fraud Investigator
It's no secret for today's health care provider that investigators from regulatory boards, insurance companies and law enforcement agencies are on the prowl looking for providers who are not following the laws & rules - with a major focus on health care fraud!
And, these investigators, especially law enforcers, are particularly interested in finding health care providers engaged in health care fraud and establishing the evidence to prosecute providers who 1) billed for services not rendered; 2) billed for services that misrepresent the nature of the services provided; 3) billed for substandard and/or unnecessary services; and/or 4) billed for services that misrepresent the actual service provider.
Law enforcement agencies, even the Fed's, have limited resources that prohibit them from investigating every provider on whom they receive information alleging health care fraud.
How do fraud investigators maximize their resources, and enhance probabilities for successful health care fraud prosecutions?
They search for easy targets! They don't have to search far! What is an easy target you ask?
Here are 9 big ones:
1. Providers who fail to deal effectively with employee or patient complaints resulting in the complaints being made to investigators to get problems resolved. Prosecutors have ready-made story-tellers to testify, if need be, as to the provider's fraudulent activity.
2. Providers who fail to recognize that ALL providers billing insurers for services rendered are under some form of investigation. The key for providers is what happens as a result of initial investigations to determine whether submitted-claims should be paid - if so, are they paid or are they being referred to SIU, regulators and/or law enforcers for further investigation.
3. Providers who have a significantly high volume of patients in one particular payment category, i.e., Medicare, Major Medical, Personal Injury, Workers' Compensation, etc. Claims-handlers see voluminous clinical and billing records from providers where either documentation or coding deficiencies, deficiencies that may otherwise have gone unnoticed, stand out - resulting in referrals for further investigation and other actions.
4. Providers who have ongoing relationships with either practice-consultants or vendors. If either these consultants/vendors or their clients become the target of a fraud investigation, such an investigation may result in providers relying on those consultant/vendor services to be dragged into an investigation. Investigators want to know, and rightly so, whether providers working with targeted consultants/ vendors were engaged in related misconduct, or have information that would further ongoing investigations. A good example of this is what happened to many providers who worked with a major MD/DC practice consultant who was successfully prosecuted.
5. Providers who aggressively market their health care services to the public - especially free services, which are not only seen by their targeted audiences but also by investigators. These efforts cause providers to become well-known (i.e., notorious) to investigators who are motivated to look a bit closer at the clinical & billing records of these very visible and high-profile providers to see if there is something that can be used to prosecute.
6. Providers who fail to completely, accurately and in a timely-manner document health care services rendered to patients. The crime scene for investigations of health care fraud is the clinical and billing records of providers. All providers have heard the saying, "If it's not documented then it didn't happen." Investigators have heard it too, and they follow this concept to a 'T'. Investigators love to find patterns, clinical files that have no notes, computer-generated notes that report similar information for all visits and patients, notes that do not support the services billed, and notes that are minimal in content - It is harder for providers to defend their actions in such instances.
7. Providers who fail to follow the payors' rules, especially when contracts are involved - where providers have agreed to follow specific terms for participation. Investigators search diligently for providers who failed to follow written-agreements. This is a strong piece of evidence for prosecutors to show juries. In such case, the contract contains the providers' signatures, agreeing to specific terms, and is used to show providers (purposefully) violated these terms.
8. Providers who fail to appropriately use billing codes (ICD-9, CPT, HCPCS) when seeking reimbursement for services rendered. Follow-the-$$$$$ is a key for investigators, and in health care fraud investigations, this process begins with the identification of inappropriate billing practices that result in payments to which providers are not entitled.
9. Providers who fail to provide appropriate oversight of their practice-activity to ensure it is consistent with the laws & rules. This is a huge mistake in today's aggressive enforcement climate, considering that for nearly a decade now, the government has strongly encouraged providers to employ compliance programs to police themselves. The absence of oversight may be used to demonstrate that the provider engaged in unlawful activity, displaying willful ignorance and acting in reckless disregard of the laws & rules. Documented oversight systems may effectively stop further investigations. Such providers are target-hardened!
At a recent seminar, a doctor asked whether law enforcers would actually go after doctors who were trying to do the right thing. The answer is - Absolutely! Trying to do the right thing and doing the right thing are two very different things. Law enforcers, armed with probable-cause that illegal activity has occurred, do not care that providers were trying to do the right thing. Remember, the investigator's sole purpose for being at the provider's practice is to collect evidence that demonstrates the provider failed to do the right thing.
Law enforcers invest a lot of time and resources investigating providers prior and subsequent to surprise visits.
The investigator's ultimate reward - A successful prosecution!
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
And, these investigators, especially law enforcers, are particularly interested in finding health care providers engaged in health care fraud and establishing the evidence to prosecute providers who 1) billed for services not rendered; 2) billed for services that misrepresent the nature of the services provided; 3) billed for substandard and/or unnecessary services; and/or 4) billed for services that misrepresent the actual service provider.
Law enforcement agencies, even the Fed's, have limited resources that prohibit them from investigating every provider on whom they receive information alleging health care fraud.
How do fraud investigators maximize their resources, and enhance probabilities for successful health care fraud prosecutions?
They search for easy targets! They don't have to search far! What is an easy target you ask?
Here are 9 big ones:
1. Providers who fail to deal effectively with employee or patient complaints resulting in the complaints being made to investigators to get problems resolved. Prosecutors have ready-made story-tellers to testify, if need be, as to the provider's fraudulent activity.
2. Providers who fail to recognize that ALL providers billing insurers for services rendered are under some form of investigation. The key for providers is what happens as a result of initial investigations to determine whether submitted-claims should be paid - if so, are they paid or are they being referred to SIU, regulators and/or law enforcers for further investigation.
3. Providers who have a significantly high volume of patients in one particular payment category, i.e., Medicare, Major Medical, Personal Injury, Workers' Compensation, etc. Claims-handlers see voluminous clinical and billing records from providers where either documentation or coding deficiencies, deficiencies that may otherwise have gone unnoticed, stand out - resulting in referrals for further investigation and other actions.
4. Providers who have ongoing relationships with either practice-consultants or vendors. If either these consultants/vendors or their clients become the target of a fraud investigation, such an investigation may result in providers relying on those consultant/vendor services to be dragged into an investigation. Investigators want to know, and rightly so, whether providers working with targeted consultants/ vendors were engaged in related misconduct, or have information that would further ongoing investigations. A good example of this is what happened to many providers who worked with a major MD/DC practice consultant who was successfully prosecuted.
5. Providers who aggressively market their health care services to the public - especially free services, which are not only seen by their targeted audiences but also by investigators. These efforts cause providers to become well-known (i.e., notorious) to investigators who are motivated to look a bit closer at the clinical & billing records of these very visible and high-profile providers to see if there is something that can be used to prosecute.
6. Providers who fail to completely, accurately and in a timely-manner document health care services rendered to patients. The crime scene for investigations of health care fraud is the clinical and billing records of providers. All providers have heard the saying, "If it's not documented then it didn't happen." Investigators have heard it too, and they follow this concept to a 'T'. Investigators love to find patterns, clinical files that have no notes, computer-generated notes that report similar information for all visits and patients, notes that do not support the services billed, and notes that are minimal in content - It is harder for providers to defend their actions in such instances.
7. Providers who fail to follow the payors' rules, especially when contracts are involved - where providers have agreed to follow specific terms for participation. Investigators search diligently for providers who failed to follow written-agreements. This is a strong piece of evidence for prosecutors to show juries. In such case, the contract contains the providers' signatures, agreeing to specific terms, and is used to show providers (purposefully) violated these terms.
8. Providers who fail to appropriately use billing codes (ICD-9, CPT, HCPCS) when seeking reimbursement for services rendered. Follow-the-$$$$$ is a key for investigators, and in health care fraud investigations, this process begins with the identification of inappropriate billing practices that result in payments to which providers are not entitled.
9. Providers who fail to provide appropriate oversight of their practice-activity to ensure it is consistent with the laws & rules. This is a huge mistake in today's aggressive enforcement climate, considering that for nearly a decade now, the government has strongly encouraged providers to employ compliance programs to police themselves. The absence of oversight may be used to demonstrate that the provider engaged in unlawful activity, displaying willful ignorance and acting in reckless disregard of the laws & rules. Documented oversight systems may effectively stop further investigations. Such providers are target-hardened!
At a recent seminar, a doctor asked whether law enforcers would actually go after doctors who were trying to do the right thing. The answer is - Absolutely! Trying to do the right thing and doing the right thing are two very different things. Law enforcers, armed with probable-cause that illegal activity has occurred, do not care that providers were trying to do the right thing. Remember, the investigator's sole purpose for being at the provider's practice is to collect evidence that demonstrates the provider failed to do the right thing.
Law enforcers invest a lot of time and resources investigating providers prior and subsequent to surprise visits.
The investigator's ultimate reward - A successful prosecution!
Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Chiropractic Compliance Consultants, Inc., 18065 238th Street,Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com
Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne
Are Carpal Tunnel Syndrome Exercises Really Effective?
Carpal Tunnel Syndrome is a common condition which occurs when the nerve that runs from the forearm into the hand becomes pressured or squeezed at the wrist. Carpal Tunnel Syndrome can occur in about 1 in every 100 people at some stage in their lifetime and the symptoms are typically pain, weakness, or numbness in the hand and wrist, moving up the arm.
Carpal Tunnel Syndrome symptoms can begin gradually, with the feeling of burning, tingling, or numbness felt in the palm of the hand and the fingers. The thumb and the index and middle fingers can be particularly affected.
Carpal Tunnel Syndrome is often caused by repetitive strain on the wrist, often because a persons work, hobby or sport dictates a repetitive motion or movement.
Carpal Tunnel Syndrome can also be due to a congenital predisposition where the physical carpal tunnel is smaller in certain people than in others. A trauma or injury to the wrist and hand area, such as a sprain or fracture, can also cause the symptoms of Carpal Tunnel Syndrome.
There are numerous treatments and proposed cures for Carpal Tunnel Syndrome but one of the most popular and straightforward self-help remedies are exercises designed to alleviate the symptoms.
Certain studies have concluded that if patients suffer from mild Carpal Tunnel symptoms then exercises can enable them to avoid surgery and provide the most effective relief when compared to other non-surgical treatments.
It is important to note that if a person suffers from severe or persistent Carpal Tunnel symptoms that they should consult their doctor or health practitioner as appropriate.
Stretching exercises performed for the hands and wrists at regular times throughout the day, even at times when no pain or discomfort is felt, can be extremely effective at managing the symptoms.
Over time you will learn the best exercises for your particular symptoms and when is the right time to perform them. Eventually you may be able to prevent the symptoms from recurring altogether or at least minimise the pain associated with the condition.
For further advice and support on Carpal Tunnel Syndrome, please visit Carpal Tunnel Syndrome
For specific Carpal Tunnel Exercises and stretches, please visit Carpal Tunnel Exercises website.
Article Source: http://EzineArticles.com/?expert=Jack_Prime
Carpal Tunnel Syndrome symptoms can begin gradually, with the feeling of burning, tingling, or numbness felt in the palm of the hand and the fingers. The thumb and the index and middle fingers can be particularly affected.
Carpal Tunnel Syndrome is often caused by repetitive strain on the wrist, often because a persons work, hobby or sport dictates a repetitive motion or movement.
Carpal Tunnel Syndrome can also be due to a congenital predisposition where the physical carpal tunnel is smaller in certain people than in others. A trauma or injury to the wrist and hand area, such as a sprain or fracture, can also cause the symptoms of Carpal Tunnel Syndrome.
There are numerous treatments and proposed cures for Carpal Tunnel Syndrome but one of the most popular and straightforward self-help remedies are exercises designed to alleviate the symptoms.
Certain studies have concluded that if patients suffer from mild Carpal Tunnel symptoms then exercises can enable them to avoid surgery and provide the most effective relief when compared to other non-surgical treatments.
It is important to note that if a person suffers from severe or persistent Carpal Tunnel symptoms that they should consult their doctor or health practitioner as appropriate.
Stretching exercises performed for the hands and wrists at regular times throughout the day, even at times when no pain or discomfort is felt, can be extremely effective at managing the symptoms.
Over time you will learn the best exercises for your particular symptoms and when is the right time to perform them. Eventually you may be able to prevent the symptoms from recurring altogether or at least minimise the pain associated with the condition.
For further advice and support on Carpal Tunnel Syndrome, please visit Carpal Tunnel Syndrome
For specific Carpal Tunnel Exercises and stretches, please visit Carpal Tunnel Exercises website.
Article Source: http://EzineArticles.com/?expert=Jack_Prime
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