Healthcare Compliance Training

Does the Insurance Industry intend to destroy Chiropractic by driving DCs out of practice by nonsensical lawsuits?

2009-10-03T06:56:00.000-07:00

[caption id="attachment_18" align="alignright" width="300" caption="Modesto DC suing for $5 million"][/caption]Friday, Oct. 02, 2009

Modesto chiropractor suing for $5M

Claim names SJ County, insurer, two DA workers

By Merrill Balassone
mbalassone@modbee.com Buzz up!

A Modesto chiropractor once charged with defrauding insurers and workers compensation out of millions of dollars wants to clear his name.

Wilmer Origel, who endured 18 days in jail, raids on his offices and suspension of his chiropractic license, filed a multi-million dollar lawsuit in federal court last week against those who unsuccessfully prosecuted him.

A San Joaquin County jury voted 10-2 in favor of acquitting Origel on charges of overbilling insurance companies in excess of $1 million, performing controversial adjustments on anesthetized patients and money laundering. Prosecutors decided not to retry Origel in November.

At 49, Origel said he's starting life over.

"I won my freedom, but they still won," he said. "I lost everything."

Origel is suing San Joaquin County, two employees of the district attorney's office and Travelers Property and Casualty Company of America, an insurance company Origel's lawyer said pulled the strings in the criminal probe.

Origel is seeking $5 million plus punitive damages.

The defendants in the case did not return calls or declined to comment on the lawsuit's specifics.

Among the case's controversial aspects is that Origel and other chiropractors performed and charged insurers for a procedure called manipulation under anesthesia.

It requires an anesthesiologist to provide pain medication before a chiropractor works on muscles or adjusts joints or the spinal column. Patients typically have such serious injuries that back or neck surgery are treatment options.

During the 2½ month trial, prosecutors alleged the procedure was illegal.

But some insurers, including the worker compensation program, cover MUAs, and the California Chiropractic Association recognizes MUAs as an alternative to more risky surgical procedures.

Origel's attorney, Rob Waters, said Traveler's Insurance pushed Origel's case forward to intimidate chiropractors from performing the expensive procedures. Prosecutors said they cost $35,000 to $40,000.

Waters said the insurance company won in one sense: Origel, who has practiced since 1989, suffered "professional death," at their hands.

"Just because an insurance company does not want to pay for a procedure does not make that procedure unnecessary or illegal," Waters said.

Origel was at the helm of Med-1 Medical Centers, a chiropractic office that also employed medical doctors. The six locations, including those in Modesto, Turlock and Ceres, are closed.

"They basically shut us down," Origel said. "They destroyed us. And I think that was their intent from the very beginning."

Origel said he filed the civil rights lawsuit in part to send a message.

"Out of 36 charges, they couldn't even get a misdemeanor," Origel said. "They didn't have a single shred of evidence. I need to strike back so they think twice before they attack an innocent person."

Bee staff writer Merrill Balassone can be reached at mbalassone@modbee.com or 578-2337.

For information on ways to effectively address the issue of healthcare fraud & abuse, a multi-billion dollar menace, contact us today for a free consultation.

Turning up the HEAT on healthcare fraud & abuse!

2009-10-02T05:01:00.001-07:00

The US Justice Department created the Health Care Fraud Prevention and Enforcement Action Team, or “HEAT,” program to put a dent in the fraud perpetrated against Medicare and Medicaid. For details on HEAT, click here

The problem with the HEAT program is that it is limited to four states and ignores the vast majority of the country.

The Justice Department claims, rather naively that:

"Most health care providers are doing the right thing and providing care with integrity. But sadly, due to the illegal actions of a small but active group of heath care fraud perpetrators, billions of dollars are stolen from taxpayers each year. Medicare fraud schemes have grown bolder and more elaborate, resulting in billions of dollars in false billings and fraud schemes which are robbing Medicare and Medicaid blind and leaving our most vulnerable citizens at
risk. Medicare fraud affects every American. Not only is waste, fraud and abuse taking critical resources out of our health care system, it contributes to the rising cost of health care for all Americans and harms the short-term and long-term solvency of these essential programs.

"Eliminating fraud will cut costs for families, businesses and the federal budget and increase the quality of services for those who need care. The U.S. Department of Health and Human Services (HHS) and U.S. Department of Justice (DOJ) are working together to help eliminate fraud and investigate fraudulent Medicare and Medicaid operators who are cheating the system. Attorney General
Eric Holder and HHS Secretary Kathleen Sebelius are taking the fight against Medicare and Medicaid fraud to a new level. They have committed senior officials from HHS and DOJ to work together on the Health Care Fraud Prevention and Enforcement Action Team (HEAT)."

The HEAT Team will expand efforts to stop fraud and prevent it from happening in the first place. These efforts will include:

Stopping Those Who Perpetrate Fraud:

• Continuing to utilize Strike Force teams that fight fraud in Miami and Los Angeles;
• Creating Strike Force teams in Detroit and Houston; and
• Helping State Medicaid officials conduct provider audits and monitor activities to detect fraudulent activities.
• Using modern technology to complete in a matter of days analysis of electronic evidence that previously took months to analyze using traditional investigative tools.
• Background on the Health Care Fraud Prevention and Enforcement Action Team.
• Criminal Prosecution as a Deterrent to Health Care Fraud, Testimony of Lanny Breuer, Assistant Attorney General for the Criminal Division, before the Senate Judiciary

Committee's Subcommittee on Crime and Drugs, 5/20/2009.

According to the Justice Department, in criminal enforcement actions during 2008, Department prosecutors:

1. Opened 957 new criminal health care fraud investigations involving 1,641 defendants, and had 1,600 criminal health care fraud investigations involving 2,580 potential defendants pending at the end of the fiscal year; and

2. Filed criminal charges in 502 health care fraud cases involving charges against 797 defendants and obtained 588 convictions for the year. Each of these figures represents an “all time high” count of federal criminal cases, defendants, and convictions.

Another 773 criminal health care fraud cases involving 1,335 defendants were pending at the end of FY 2008. In 2008, the Government charged 37 defendants in 21 indictments involving more than $55 million in fraudulent Medicare claims .

Since its inception two years ago, the Strike Force, with a limited number of investigators and prosecutors, has:

• filed 108 cases charging 196 defendants who collectively billed the Medicare program more than half a billion dollars;
• taken 129 guilty pleas;
• handled 14 jury trials resulting in convictions of 18 defendants; and
• obtained 109 sentences of imprisonment, ranging from 30 years to 4 months of home confinement, with an average term of imprisonment of 48 months.

It seems strange to hear politicians claim that they will save $500 billion by reducing fraud and abuse when with a special task force in place the US filed only 108 cases charging 196 defendants in two years and took only 14 cases to trial regarding 18 defendants with minimal recoveries from the participants. To effectively limit health insurance fraud (both against government and private
insurance programs) that steal over $100 billion every year it will be necessary to do more than pilot projects that have only covered four cities in four years.

It is time to properly fund the enforcement divisions and get more serious verdicts like some of those reported in the “Good News” sections below.

For more information on this and related topics, click here.

Should chiropractors ignore coding requirements for "mechanical traction" and EMS?

2009-03-25T05:02:00.000-07:00

LOCAL CHIROPRACTOR SENTENCED TO 5 YEARS IN FEDERAL PRISON FOR HEALTH CARE FRAUD

Atlanta, GA—DR. WILLIAM STEARNS, DC, 47, of Marietta, Georgia, was sentenced late yesterday to serve five years in prison by Senior United States District Court Judge Clarence Cooper, for participating in a $2 million health care fraud scam at the network of back pain clinics that he operated with two co-conspirators. STEARNS was convicted after a two-week jury trial in October 2008.

United States Attorney David E. Nahmias said, “This sentence is another reminder that health care providers who fraudulently bill for their services will be held accountable for their crimes. These defendant and his partners received millions of dollars to which they were not entitled, by lying to insurers about the services they were providing patients. Such lies contribute to the problem of soaring health costs for all, and those responsible may end up spending years in prison.”

STEARNS was sentenced to serve five years in federal prison, to be followed by 3 years of supervised release. There is no parole in the federal system. He was also ordered to pay $1.2 million in restitution.

According to United States Attorney Nahmias and the information presented in court: In 2004, STEARNS and two partners, fellow chiropractors STEVEN LEVINE and CHRISTOPHER TOPEL, operated three clinics around the Atlanta area under the name Comprehensive Care Medical Group (“CCMG”). CCMG, under the direction of STEARNS, fraudulently billed Blue Cross/Blue Shield of Georgia for two separate back pain procedures, costing that insurer alone approximately $2 million.

First, STEARNS and his partners fraudulently billed for a procedure known as Vertebral Axial Decompression (“VAX-D”)—a non-invasive back pain procedure that uses a mechanical table to stretch a patient’s spine.

Blue Cross/Blue Shield of Georgia considers VAX-D to be investigational and not medically necessary, and made clear to health care providers that it did not cover the procedure.

STEARNS, along with LEVINE and TOPEL, were convicted of having lied to Blue Cross about what procedures they were performing in order to get paid for this non-covered procedure.

Specifically, instead of using the specific billing code assigned to VAX-D, CCMG used a different code that pertained to surgical nerve decompression procedures. The Indictment charged that STEARNS used that code because he and the others knew Blue Cross would pay for it, and would not pay for VAX-D. The proof at trial included testimony from the STEARNS’ former employees, several of whom were explicitly instructed to not refer to the procedure as “VAX-D” in patient files.

In addition, STEARNS also fraudulently billed for an electrical stimulation procedure using a device known as “Hako-Med.” Instead of billing for a relatively low-paying electrical stimulation procedure, the Defendant instead claimed to be performing surgical procedures known as nerve block injections. This was false, but allowed STEARNS to bill for rates five to ten times as high as if he had correctly billed for electrical stimulation.

The defendants were initially charged in an indictment in March 2007. Both LEVINE and TOPEL previously pleaded guilty. TOPEL previously received a sentence of 2 years, 10 months’ in federal prison. LEVINE’s sentencing is scheduled for March 17, 2009, at 4 p.m., before Judge Cooper.

This case is one of a series in which the United States has obtained convictions against medical professionals who have fraudulently billed insurance companies for “VAX-D.” All together, the VAX-D initiative in the Northern District of Georgia has resulted in 7 convictions of medical professionals, 6 of whom have been sentenced so far to a total of 19 years of imprisonment with monetary judgments over $8 million.

This and other VAX-D cases have been investigated by Special Agents of the Federal Bureau of Investigation.

Assistant United States Attorneys Justin S. Anand and Teresa D. Hoyt are prosecuting these cases.

For further information please contact David E. Nahmias (pronounced NAH-me-us), United States Attorney, or Charysse L. Alexander, Executive Assistant United States Attorney, through Patrick Crosby, Public Affairs Officer, U.S. Attorney’s Office, at (404) 581-6016. The Internet address for the HomePage for the U.S. Attorney’s Office for the Northern District of Georgia is www.usdoj.gov/usao/gan.

Doctors Fight Back Against Denial by Algorithm - Miller McCune (March 7, 2009)

2009-03-07T05:05:00.000-08:00

The technological "arms-race"
between insurers and providers continues

The man President Obama originally wanted to oversee his dream of affordable health insurance for most Americans, former Sen. Tom Daschle, withdrew his nomination for Health and Human Services secretary in early February. While tax issues were the headline reason he bailed, the financial disclosure statement he filed with the Office of Government Ethics revealed the health care industry — which he was about to regulate — paid Daschle more than $200,000 over the past two years in consulting and speaking engagements.

Included in one of those speaking appearances was an exclusive, invitation-only conference in May 2008 at the Gaylord Palms Resort in Orlando, Fla., held by Ingenix, a research firm owned by UnitedHealth Group, one of the nation’s largest health insurers. Daschle gave the keynote address.

At the time of the conference, Ingenix was openly under investigation by New York Attorney General Andrew Cuomo in a case involving UnitedHealth and Aetna, which was settled in January. The suit alleged a conspiracy to lower health insurance reimbursements when patients see a doctor outside their provider network; Cuomo said patients were defrauded of hundreds of millions of dollars of unpaid claims.

“For the past 10 years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry,” Cuomo said in January. “This agreement marks the end of that flawed system.”

One flawed system may have ended, but another persists even as the president tries find experts not tangled in conflicts of interest to recast the $3 trillion American health care system to focus on health and not money.

As Miller-McCune.com reported a year ago, companies such as Ingenix produce what insurers call “claims review programs,” but which those on the receiving end call “denial engines.” These computer programs sift through millions of submitted claims to, in essence, lower the amount of money insurance companies pay out to doctors. Insurers see this as cost containment, and any shortfall between what the doctor charges and what’s received generally gets passed on to the patient.

Now doctors are fighting back, settling for hundreds of millions of dollars with the help of the AMA and consultants who are trying to quantify the losses with hard numbers.

Driving denials
Ingenix’s dozens of digital products primarily analyze health insurance claims data. They help hospitals determine average fees and help physicians manage their billing, but mostly they help insurers scrutinize submitted charges.

The program under fire by Cuomo allegedly cooked the numbers in a database that collected out-of-network charges. When insurers paid the average cost of a particular service, the “usual and customary” rate, they artificially – and intentionally, said Cuomo — lowered that rate.

Using technology to reduce payments to physicians for out-of-network services just touches the surface of physician discontent. Doctors argue that insurers underpay or flat out deny, as a matter of course, legitimate health insurance claims worth billions of dollars each year. This in turn costs them more in lost time and money to recover. They say, in the end, it’s the patients who suffer, paying more and getting less when insurers use secretive methods that rely on proprietary software.

There’s a virtual arms race taking place between hospitals and physician groups on one side and insurance companies on the other, each spending millions of dollars on software programs and claims reviewers to counteract their losses. Leading software designers include IBM, McKesson, Bloodhound Technologies, TC3 Health and Fair Isaac (which sold the claims review part of its business to Mitchell International last May). These companies boast their products can reduce insurance payments between 3 percent and 7 percent.

The extent to how often insurers use computer-generated edits to reduce payments varies widely — anywhere from less than 0.5 percent to more than 9 percent — according to the AMA’s National Health Insurance Report Card. The use of “undisclosed proprietary edits” to reduce payments — as opposed to publicly stated reasons for the reduction — varied from none at all to nearly 72 percent of the time. This lack of transparency largely contributes to doctors’ frustration, said Frank Cohn, senior policy analyst for MIT Solutions a health care consultant firm to physicians and hospitals.

“We’re trying to put medical practices on an even playing field with the payers,” Cohn said.

Insurers say the programs improve efficiency and save costs through real-time billing where patients can see what they owe and doctors know how much they’ll get paid right at the time of service, said Robert Zirkelbach, spokesman for America’s Health Insurance Plans, an industry trade group. Insurers reduce administrative costs through computer edits, in some cases offering cash back to doctors if they submit claims electronically.

Drawing the line
Attempting to put a cost to this, the American Medical Association last June tapped a group of consultants to analyze 5 million claims records from Medicare and seven national health insurers.

The study found that “inefficient and unpredictable” claims-review procedures by insurers cost the health care system $210 billion annually, diverting roughly 14 percent of physician resources. The research led to a campaign the AMA calls “Heal the Claims Process.”

Dr. William A. Dolan, a member of the AMA board of trustees, said doctors should be spending no more than 1 percent of their revenue on billing. As an orthopedic surgeon in New York, Dolan has seen bills for certain types of surgery automatically get bumped to a similar surgery with a lower reimbursement rate. He draws a distinction between sifting out fraud and the automatic denials or requests for medical records that insurers impose. The latter, he said, simply exist so insurers can pay less.
“There is medical fraud on the part of doctors, but that’s a small number of people,” Dolan asserted. “You can catch various forms of fraud with different software that identify certain codes. But here are insurance companies committing fraud by downright underpaying physicians for their work.”

Some companies are selling programs to both sides of the battle (to payers and providers), but in a war that insurers are by and large winning, doctors and hospitals should be skeptical of this dual role, said Cohn.

“It’s like owning a military base on a communist island or renting a room to my ex-wife,” he joked.

While such computer programs play a worthy role in capturing a fraction of the billions of dollars in likely fraud, for the honest physician, these programs cause far more problems than they solve, Cohn said. Typically more than half of denied claims challenged by doctors are overturned on review, he said.

“What would you think of a judge who had 60 to 70 percent of cases overruled on appeal?” he asked, pointing to “denial engines” as the primary culprit.

A worthy role
Insurers by and large defend their billing software as useful tools to reduce administrative costs and improve care. The federal stimulus bill, with $2 billion for health information technology, should increase the use of computerized billing, an aspect sometimes lost by attention on electronic medical records, Zirkelbach said.

“As new technologies come on the scene, health plans are assessing their ability to streamline the billing process and ultimately improve the care patients receive,” Zirkelbach said. “There is a lot of evidence showing that new (billing) technologies are making things better.”

Billing software can allow a doctor to spend less time with balance sheets and more time with patients. Insurers can also use claims data to help doctors better comply with evidence-based medicine and make some determinations about quality, ferreting out such things as how many cardiac patients might return to the hospital within 90-days.

Not long ago, doctors made a similar advance against insurance companies. A series of settlements between the AMA and major insurers, including with Aetna in 2003 and Blue Cross plans in 2007 worth hundreds of millions of dollars, focused on diminishing the administrative hassles by insurers.

UnitedHealth and Ingenix declined to comment directly for this story, instead pointing to press releases. Aetna issued a lengthy written response touting numerous efforts to improve electronic billing since the 2003 settlement. Out of 1.6 million claims filed per year, 79 percent are submitted electronically and 80 percent are paid within 2.6 days, said Paul Marchetti, head of Aetna's national network and contracting services. He likened what Aetna does to a similar program under Medicare.

“Aetna’s claim system is a highly customized platform designed to meet Aetna’s commitment to paying physicians and other health care providers quickly and accurately,” Marchetti said.

In recent years, Aetna launched several initiatives designed at paying claims on time, correctly and transparently when there are denials or corrections — all with the assistance of software vendors and an online tool called NaviNet, where doctors can submit claims to multiple insurers through a single portal.

“Aetna is helping take the administrative hassle out of medicine,” Marchetti said. “That’s why we are aggressively investing in e-technology and introducing new services that directly help physicians and hospitals run successful practices and focus on the thing that matters most: caring for their patients.”

Insurers settle out-of-network
In the January settlement Cuomo hammered out, a nonprofit group will replace Ingenix in managing the database for out-of-network charges. UnitedHealth agreed to pay $50 million and Aetna $20 million toward its operation. Settlements with other insurers continue.

A few days after the civil settlement with Cuomo, the AMA announced a settlement of its own with UnitedHealth: $350 million, directed to physicians and plan holders. On Feb. 10, the AMA said it would join a similar suit against Cigna and Aetna. Referring to out-of-network charges, the AMA says the insurers used “rigged data to dramatically under-reimburse physicians,” according to a press release.

“(Insurers) haven’t been punished hard enough,” said Dolan, with the AMA. “Even $350 million can be peanuts to these companies.”

Marchetti called the AMA lawsuit “disappointing.”

“This will not help advance what we believe is our mutual desire to transform health care,” he said.
For others, the financial reparations may not be enough. “I’m disappointed Cuomo settled the way he did,” said Cohn, who worked with Cuomo’s office in devising an alternate fee schedule to the Ingenix program. “I’m all for physicians who commit fraud going to jail, but who’s out there putting payers who commit fraud in jail? Apparently they just have to pay a fine.”

Does United Healthcare Discriminate Against Chiropractors?

2009-02-26T15:22:00.000-08:00

Who's "at it" again?

In an article titled, "United Healthcare: Here They Go Again" (Dynamic Chiropractic - April 9, 2007, Vol. 25, Issue 08), James D. Edwards, D.C., currently serving as an "Alternate Delegate" ("Tx-East") in the American Chiropractic Association, stated:

The American Chiropractic Association (ACA) has received reports that United Healthcare has implemented a new policy in several states to only reimburse physical medicine and rehabilitation (PM&R) services when performed by a licensed provider.

The new policy states, "PM&R services rendered by non-licensed individuals are not eligible for reimbursement, regardless of whether they are supervised by, or billed by a physician or other licensed therapy provider." This change is effective as of Jan. 1, 2007 for newly contracted providers and April 1, 2007 for currently contracted providers.

So, what exactly does this new policy mean for doctors of chiropractic? In Texas, where United Healthcare is applying the policy, it means a doctor of chiropractic will not be reimbursed for physical medicine or rehabilitative treatments unless those services are actually performed by the doctor or by a person licensed by the state to do so . . ..

Does Dr. Edwards actually identify a disparate situation for chiropractors vis-à-vis other licensed healthcare providers (e.g., MD, DO, PT, OT)? There is no evidence of such a disparity, at least per the reference cited.

However, there can be little doubt that chiropractors perform such services at a much higher rate than other physician-providers on a per-capita basis.

Does Dr. Edwards identify a new policy in reimbursement-standards within the Insurance industry? Dr. Edwards states, "[T]his change will greatly impact patients and providers across the country . . .." He goes on to state:

[I]f you are a non-licensed chiropractic assistant who applies a heat pack or assists a patient with rehab, you will not be reimbursed! Think that might change the way you practice? (ibid.)

I am unaware of any insurance carrier that will "reimburse" a "non-licensed chiropractic assistant." Furthermore, I'm not certain that the position articulated correctly posits United Healthcare's reimbursement standard(s).

It is significant to note that the CPT Guides are unequivocal in distinguishing between supervised and attended modalities. Additionally, CPT distinguishes between "modalities" and "therapies" in the following manner:

Modalities are defined as "Any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy." They may be attended or non-attended.

The definition of modalities was added to CPT 1995 to indicate the different types of service included in this section.

To clarify the work performed by the provider, the section is divided into two parts; Supervised and Constant Attendance.

• Supervised modalities are defined as the application of a modality that does not require direct (one on one) patient contact by the provider.
• Constant Attendance is defined as the application of a modality that requires direct (one on one) patient contact by the provider.

Therapeutic Procedures are defined as "A manner of affecting change through the application of clinical skills and/or services that attempt to improve function." These require direct patient contact.

The definition of therapeutic procedures was added to CPT 1995 to clarify the differences between therapeutic procedures, modalities, and tests and measurements. These procedures require direct one on one patient contact by a physician or therapist. [At times, the foregoing terms are collectively referred to as "Provider" by CPT - both meaning someone licensed by the State to perform health care services.]

Therapies is a kind of general term used by many people to describe all physical medicine procedures -- modalities, therapeutic procedures, acupuncture, and sometimes, even CMT.

Most insurance companies will refer to the CPT terms described above. (http://www.chiro.org/ChiroAssistant/Articles/Modalities_vs_Therapies.shtml)

It would appear that United Healthcare is merely applying the applicable CPT codes in the manner the AMA CPT Guides intended. It is not clear why Dr. Edwards perceives that the application of the codes in the manner intended would justify issuing this alarming statement:

The NCLAF ["National Chiropractic Legal Action Fund"] has repeatedly told the chiropractic profession that the concern is not if our adversaries will attack us again, but when they will attack us. And sure enough, here they go again. Fortunately, the NCLAF shifted its focus to building a legal "war chest" for just this type of attack, and has reserves ready to commit to the fight. The ACA and the NCLAF continue to protect and defend your practice, your patients and your profession.

I know of few chiropractors who would not be concerned regarding the current insurance-reimbursement landscape, particularly as it pertains to Chiropractic. However, is the fact that chiropractors are treated in the same manner as other similarly-situated providers justification to break open the "war chest" and rally the troops?

The Chiropractic profession has much to offer the Healthcare community. As we, as a profession, consider what it is that we have to offer, we should proceed judiciously in that arena in which we have clamored for parity for decades, threatening to play the "victim" card when we finally receive the parity for which the battle was fought.

It appears as though one may justifiably ask, "Is it United Healthcare or the Chiropractic profession that is 'at it' again?"

About the Authors:

Dr. Tom Rhudy is licensed as both an Attorney and Doctor of Chiropractic in the states of Texas and Missouri. Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance.

For the past 20+ years the authors have devoted most of their efforts toward educating and assisting providers in the development of healthcare treatment and compliance programs and prevention of healthcare fraud and abuse, making every effort to improve the quality of care and representation provided to patients.

For more information about creating an effective Healthcare Compliance program, designed to prevent healthcare fraud and reduce healthcare costs, you may go here: http://www.HealthCareComplianceTraining.net

Do Healthcare Compliance Programs Prevent Healthcare Fraud and Reduce Healthcare Costs? Part III

2009-02-25T05:13:00.000-08:00

Okay, now that you've developed your Healthcare Compliance policies and procedures, what's the next step? Great question!

After all, if you have policies and procedures, but no implementation, is the program effective? How would such an inert Healthcare Compliance program prevent healthcare fraud and reduce healthcare costs? You're right, it wouldn't.

I have provided a few recommendations regarding ways in which to conduct effective training for your Healthcare Compliance program. (I've also shared a few lessons learned along the way.)

Training Sessions: Once the foregoing are completed, it will be necessary to set a time and place for the training session(s). It is important to conduct the training in a manner most likely to capture the largest number of employees/agents for which the training is intended. Any employees/agents who do not attend the plenary training session should be required to either attend a make-up training session or provide evidence of having obtained the information contained in the training session.

Training Location: Ensure that the location of the training session is conducive to such training, and interruptions will be minimized. During one of our first compliance training sessions, the room in which we conducted the training was so hot that by the time we were finished, participants were practically stripped down to their underwear.

Sound System: Ensure that you have an adequate sound-system. Too often, speakers conclude that they do not need a sound-system. Remember, sound-systems are for the listeners, not the speakers. It is also important to avoid having individuals attending the training session sit in areas that are “dead-spots,” acoustically-speaking.

Sign-In Sheets: Provide a sign-in sheet, identifying the date on which the training session is conducted, the employee’s/agent’s printed name, and the employee’s/agent’s signature.

Pre-Test: Provide Pre-Test 1A to all employees/agents to determine the knowledge- base of the participants prior to the training.

Videotaping Training Session: Training sessions should be memorialized, preferably via video. It is recommended that the taping, irrespective of the medium, be performed by a professional. If you do not know where to obtain such a professional, it is recommended that you contact a court-reporting service for recommendations. It is difficult to convince investigators that you take your compliance training seriously when an inattentive videographer allows the camera to focus on the back of someone’s head for ten minutes and the audio includes private discussions amongst audience members.

Q&A: Conduct a Q&A session following the training. Remember the following: (a) have speakers repeat questions asked; (b) ask participants to rephrase ambiguous questions; and (c) refrain from addressing questions that are not relevant to the training session, stating that you will be happy to discuss the issue with the questioner at a convenient time following the training session.

Post-Test: Provide Post-Test 1A to all employees/agents to determine the knowledge-base of participants following the training session. This will be a good metric to assess the effectiveness of the training session.

I hope that this is beneficial. Remember, if you have additional questions, please feel free to contact me.

You may obtain additional information regarding ways in which to design an effective Healthcare Compliance program, a program that has demonstrated its effectiveness in preventing healthcare fraud and reducing healthcare costs, by going here:
http://www.HealthCareComplianceTraining.net

Do effective Healthcare Compliance Programs prevent healthcare fraud and reduce healthcare costs? Part II

2009-02-24T05:13:00.000-08:00

Delegation of Duties: It will be necessary to appoint a Compliance Officer who is qualified to oversee a healthcare compliance program. If you do not have an employee in your organization with such training, we have provided, and make available additional, resources that will prepare the appointed individual to assume such a role.

1. Compliance Officer: The individual appointed must be someone who refuses to compromise the quality and integrity of the compliance program. Policies pertaining to billing, coding, documentation, etc. should be viewed as mandatory, not optional!
2. Compliance Committee: Once your Compliance Officer is appointed, it will be necessary to determine what departments within your practice should be represented on a Compliance Committee to which the Compliance Officer will report. Frequently, providers mistakenly conclude that the practice consists of only one department. Rarely would this be the case.

Most practices will have, if nothing else, the following: (1) record keeping; (2) billing; (3) collections; and (4) production. Although one individual may wear hats for each department, it is best to consider these departments as discrete entities. This permits more effective management and analysis of your overall practice.

Compliance Manual: The Compliance Manual we have prepared addresses areas of exposure to which attention must be directed to attenuate (i.e., lessen) the exposure arising in each area. This is one of the most critical areas of any compliance program, and should not be given short-shrift.

Employee Manual: We have also provided an Employee Manual in which examples of employees’ duties and responsibilities are provided. It is recommended that the manual be tailored to the individual practice. While the duties and responsibilities included pertain to the principal areas of most healthcare practices, undoubtedly your practice has one or more unique areas that would benefit from slight modification of this manual.

Vendor/Agent Contracts: We have also included sample contracts to be used when working with vendors, independent agents, and licensed providers who are not employees of your organization.

Hotline: We have provided Hotline protocol, intended to provide a viable reporting mechanism for concerns/complaints concerning the organization’s practices. This protocol is effective in providing a reporting mechanism for concerns/complaints arising either internally (i.e., employees) or externally (e.g., patients, insurance adjusters et al.).

Education: The policies/procedures contained in the manual serve as an excellent educational tool for all employees, agents et al. However, to be effective, as is true for all education, it is necessary for those policies and procedures to animate those with whom they are shared. Merely having a dormant document in which such policies/ procedures are contained will not accomplish your intended goal of developing a vibrant bona fide healthcare compliance program.

Disciplinary Procedures: We have provided a guide to Disciplinary Procedures, applicable to both licensed and unlicensed employees. It is important to bifurcate these disciplinary procedures to ensure licensed providers that they are the individuals to whom boards of examiners will look for accountability, to whom law enforcement will look as the instigator of abusive and unnecessary procedures, and to whom governmental agencies will address inquiries into questionable/unusual practices. Unlicensed individuals must realize that their activities may also result in the accrual of personal criminal liability. Neither licensed nor unlicensed individuals are immune from prosecution. I was involved in one investigation in which a provider whose name was affixed to billing statements had been dead for more than six months, and the office manager’s sentence was actually longer than the doctors’.

Exit Interview: We have provided an Exit Interview form, as well as procedures to follow when employees sever their employment relationship, whether it be voluntary or otherwise. Failure to perform this procedure may result in many unnecessary claims (e.g., wrongful termination, “whistle-blower” actions, etc.) and prove extremely costly.

About the Author:

Dr. Tom Rhudy is licensed as both an Attorney and Doctor of Chiropractic in the states of Texas and Missouri. While serving as both an Attorney and Doctor of Chiropractic, he has worked closely with law enforcement, insurance carriers, administrative agencies, the FBI, US Attorney's Office, the US Postal Inspector's Office, and healthcare providers in the prevention, investigation, and prosecution of healthcare fraud.

For the past 20+ years he has devoted most of his efforts toward educating and assisting providers in the development of healthcare treatment and compliance programs and prevention of healthcare fraud and abuse, making every effort to improve the quality of care and representation provided to patients.

To obtain assistance in developing an efective healthcare compliance program, you may check us out here:
http://www.HealthCareComplianceTraining.net

Can an Effective Healthcare Compliance Program Prevent Healthcare Fraud and Reduce Healthcare Costs?

2009-02-23T05:29:00.000-08:00

If you realize that you need a healthcare compliance program, but feel apprehensive about what seems to be such a daunting task, this Guide will assist you in gaining the confidence that you need to proceed step-by-step in creating a healthcare compliance program that will make you proud to be a healthcare provider once again. This Guide will show you the most important elements to consider in the development of a compliance program, irrespective of the size of your practice.

It is dangerous to assume that because your practice is small (e.g., 1 doctor and 1-2
staff members), that you do not need to have such a program. Any healthcare practice can become the target of a fraud investigation!

The following steps, if followed closely, will get you well on your way to a bona fide compliance program:

Practice Analysis: First, and foremost, it will be necessary to assess the areas of your practice that pose the greatest liabilities. To determine this, you will need to consider the following:

1. Do you provide healthcare to patients who are either employees of the Federal Government who will be filing claims against/with their employers’ carrier, or who will be filing claims under a government contract (e.g., Medicare/ Medicaid)?
2. Do you accept Letters of Protection on 3rd-party liability claims?
3. Do you have high employee turnover?
4. Do you file your billing electronically?
5. Do you out-source your collections?
6. Do you contract with independent practitioners?
7. Do you contract with outside vendors?
8. Have any of your providers been sued for malpractice?
9. What percentage of your billings are denied/reduced?
10. Do you have a mechanism for responding to either denials or reductions in reimbursement?
11. Do you provide ongoing training to billing and collections employees regarding CPT coding and ICD-9 coding?
12. Do you perform background investigations on all employees prior to hire?
13. Do you provide a mechanism for reporting complaints for internal resolution?

Once this assessment is competed, it will be necessary to develop policies and procedures to allow management of each potential liability. The Compliance Manual that we have created addresses those areas that pose the greatest liabilities for the largest number of providers. It is inadvisable to merely implement these policies prior to performing a thorough analysis of your individual practice needs.

For more tips on developing your Healthcare Compliance program to prevent healthcare fraud and reduce healthcare costs, visit us at:
http://HealthCareComplianceTraining.net/

Not Enough Lawyers! Are You Kidding Me????

2009-02-16T04:37:00.000-08:00

Not enough lawyers?

Staff shortages hit local federal prosecutors' offices; vacancies affecting cases
BY ANTHONY M. DESTEFANO | anthony.destefano@newsday.com
5:05 PM EST, February 15, 2009
Overworked and understaffed.

That sounds like many workplaces, and it includes the offices of local federal prosecutors.

At a time when Wall Street wrongdoing is a major national concern, recent Department of Justice statistics show local federal prosecutions of white-collar crime and securities fraud have dropped off from higher levels earlier in the decade.

One reason for the drop, although prosecutions have picked up in recent months, may be staffing shortages and unfilled lawyer jobs in the U.S. Attorney's offices based in Brooklyn and Manhattan, according to a recent Department of Justice Office of Inspector General report. Another reason may be a drop in recent years in referrals for white-collar crime prosecution from federal agencies.

Severe in Eastern District

The staffing impact has been most severe in the Eastern District, which covers Long Island, Queens, Brooklyn and Staten Island. But even the Southern District, which covers Manhattan, the Bronx and six nearby upstate counties, appears to have shifted staff from priorities like counterterrorism and firearms to health care fraud and drug cases, according to the study.

The audit, which was released late last year and covered all 94 federal districts, showed unfilled staff positions in local federal prosecutors' offices between fiscal years 2002 and 2007. The report also signaled that federal prosecutors nationwide have been lax or uneven in the way they comply with Justice Department record-keeping requirements.

A spokeswoman for the U.S. Attorney's office in Manhattan acknowledged that the office underreported attorney work hours before 2007, not reflecting the effort in various investigative areas. The office has been working to rectify it, she said. A spokesman for the Eastern District declined to comment about the office's record keeping and deployment.

Budget problems blamed

According to Justice Department officials, the reduction in filled attorney jobs is rooted in federal budget problems.

"This underutilization occurred primarily because (prosecutors) had limited budgets to address annual rising costs, such as cost-of-living adjustments and increases in rent," said the report. "As a result, (federal) officials said (prosecutors) did not have adequate funds remaining to fill vacant positions."

"At some point they just stopped hiring," said one former Eastern District prosecutor, who asked not to be identified.

Under interim U.S. Attorney Benton Campbell, appointed in October 2007, the Eastern District has since gone on a feverish hiring binge, employing 60 new prosecutors as 29 left, for a net gain of 31, said spokesman Robert Nardoza. The office has five vacancies out of 178 attorney spots, he added. A spokeswoman for the Southern District said the office had 219 attorneys.

But even with more prosecutors, overall indictments in the Eastern District fell 33 percent from fiscal year 2003 to 2008, according to government data compiled and released by the nonprofit Transactional Records Access Clearinghouse, affiliated with Syracuse University. The Southern District's drop was 17.8 percent.

Securities fraud cases up 200%

White-collar crime and securities fraud prosecutions in both districts also fell in that period, though they recovered substantially in 2008 in the Eastern District, with securities fraud cases jumping 200 percent in a year, TRAC data showed. Among those cases were the pending indictments against former Bear Stearns hedge fund managers Ralph Cioffi and Matthew Tannin. (The arrest of Nicholas Cosmo in the suspected Ponzi scheme at Agape World Inc. occurred in fiscal year 2009 and won't show up in federal data until later this year.)

But in Manhattan, the drop in Wall Street securities fraud cases has been marked, with a 71 percent decline from 2003 to 2008, although all white-collar cases are off only an average of 17 percent, according to TRAC.

"I am not surprised at all," prominent defense attorney Gerald Lefcourt said of the Manhattan trends. He said that prosecutors used massive resources in one tax fraud case surrounding accounting giant KPMG, which he was involved in. The case against many of the 19 defendants was dismissed before the October 2008 trial, in which three defendants were convicted and one acquitted. With so much effort on one case, combined with the need for federal agents to work on terrorism, Lefcourt said the drop is understandable.

Others agreed. "Most of them (securities cases) are very difficult cases," said Fordham University Law School professor James Cohen.

"Many of the white-collar prosecutions have come from internal investigations that private law firms do," said defense attorney and white-collar crime specialist Elkan Abramovitz. TRAC data showed that white-collar crime prosecution referrals from the FBI and other agencies to the Southern and Eastern Districts dropped by more than 50 percent from fiscal year 2002 to fiscal year 2008.

Federal prosecutors in the Eastern and Southern Districts declined to comment on the TRAC data.

Where Judges Can Be Bought and Sold

2009-02-13T18:18:00.000-08:00

Where Judges Can Be Bought and Sold

Sandra Day O'Connor: Where Judges Can Be Bought and Sold

Published: January 28, 2009 in Knowledge@W.P. Carey

The story sounds just like a John Grisham novel: The CEO of a West Virginia energy company spent more than $3 million to help a relative unknown unseat the incumbent and become a judge on the state's Supreme Court.

Later, that same judge, after refusing to recuse himself, cast the deciding vote on two decisions overruling verdicts against the energy company -- verdicts now worth $82 million.

Retired Supreme Court Justice Sandra Day O'Connor isn't shy about her opinion on the matter -- states should do away with judicial elections in order to restore independence to their courts, she said recently at an Economic Club of Phoenix luncheon, co-sponsored by the W. P. Carey School of Business and the Sandra Day O'Connor College of Law at ASU.

The plaintiffs in the West Virginia case -- who were awarded the $82 million verdicts in West Virginia's lower courts and then denied the verdicts by the state's Supreme Court -- are asking the U.S. Supreme Court to make it illegal for a state justice to vote on decisions involving people or groups that made significant contributions to the justice's election campaign.

What surprises O'Connor about the case, she said, is that the state allowed such bias into the courtroom in the first place. The argument shouldn't be about whether a judge should be forced to recuse himself from cases with litigants who financed his election campaign. Instead, O'Connor said, it should center on whether judges should be elected at all.

"I don't know what the constitution has to say about this or what the Supreme Court will do, but it strikes me as a sad state of affairs when a case like this becomes a question of constitutionality when it's clearly bad policy for the state to allow that environment to exist in the first place," she said.

Keeping the field level

"The basic precept of equal justice under the law requires that neither side of the dispute has an unfair advantage," Justice O'Connor said. "I think you might be concerned if you were in court litigating some issue in front of a judge who had been given a bunch of money by your opponent."

Alan Page, a National Football League Hall of Famer and Minnesota State Supreme Court Justice, compared a lack of judicial independence to how football fans would feel if, before their favorite team took the field, they learned that the officials for the game had a stated preference for seeing one side or the other win. "Or if the referees had to campaign for their jobs while being funded by the opposing team -- that's what we're facing today," said O'Connor.

Arizona does a good job of maintaining judicial independence through a system that selects most judges based on merit, O'Connor said. Yet a majority of states still elect state judges in partisan elections -- a fact that O'Connor said is "shocking."

The United States is the only country in the world that elects judges.

"People around the world are shocked that is our system," O'Connor said. But judicial election was never the intention of the country's founders. "Originally states' governors selected judges with confirmation by the states' senates," she said. "But then the great populist President Andrew Jackson persuaded Georgia to begin electing its judges -- and many states, including Arizona, followed suit."

In 1974 -- when Justice O'Connor was herself serving in the Arizona State Senate -- legislators amended the state's constitution to mandate a judicial selection system for most judges. Today, the governor appoints appellate court judges statewide and superior court judges in Maricopa and Pima Counties from a list of nominees submitted by judicial nominating commissions. Once appointed, the judges are retained or rejected by the voters every four years for superior court and six years for the appellate courts.

Arizona's current merit selection system is one of the best in the nation, O'Connor said. Nevertheless, she said, some of Arizona's legislators continue to fight to go back to the old election system, "with all the money changing hands and the problems that produces."
"Don't let that happen," she cautioned.

"If I could do one thing to protect judicial independence in this country," O'Connor said, "it would be to convince those states that still elect their judges to adopt a merit selection system and -- short of that -- at least do something to remove the vast sums of money being collected by judicial candidates, usually from litigants who appear before them in the courtroom."

The importance of judicial independence

Justice O'Connor said that the threat posed by the "flood of money into courtrooms by way of increasingly expensive and volatile judicial elections" is huge. The issue extends far beyond the courts, as decisions that judges make influence government, businesses and individuals. If those decisions are swayed by money, O'Connor said, everyone loses. "

A fair and impartial judiciary is absolutely fundamental to a properly functioning business and economic climate," she said.

Speaking after Justice O'Connor, W. P. Carey School of Business Dean Robert Mittelstaedt echoed the importance of judicial independence for business. "Economics always works," he said, "but it works best with the rule of law."

Some of the country's largest businesses seem to agree.

A "friends of the court" brief filed with the U.S. Supreme Court by Wal-Mart, Lockheed Martin, Intel Corp. and PepsiCo in advance of oral arguments in the West Virginia case says that "There is a need to signal to businesses and the general public that judicial decisions cannot be bought and sold."

Impartiality among justices is also important, O'Connor said, because the country needs the two other branches of government -- the executive and legislative branches -- to follow judicial orders. "To achieve that, they need to have confidence in a fair and impartial judiciary." Which, ostensibly, is hard to ask for when judgeships can be bought.

Furthermore, the judicial system, O'Connor said, needs judges with the courage to decide against the majority. Whether it's going against popular opinion, or the political leanings of a prominent politician, or a particular business interest, judges that are appointed for their merit are more likely to have that courage, she suggested.

When asked about whether merit-based judicial selection circumvents the will of the people, O'Connor said that she advocates a merit-based selection system with periodic retention elections -- like Arizona's -- where voters can vote "Yes" or "No" to retain a sitting judge. "That ought to be plenty of power for the electorate," she said.

To find out what happened when judicial independence was brought into question by corporate money in John Grisham's latest novel, read "The Appeal." To find out how the oddly similar real-life story ends, stay tuned for the U.S. Supreme Court's ruling; the Court is scheduled to hear the case beginning on March 3.

Yet no matter what her former colleagues decide, Justice O'Connor, for one, would like states to adopt their own merit-based selection systems, so cases like the West Virginia one don't happen in the first place.

Bottom Line:

Retired Supreme Court Justice Sandra Day O'Connor said that states should do away with judicial elections in order to restore independence to their courts.

Arizona does a good job of maintaining judicial independence through a system that selects most judges based on merit. But a majority of states still elect state judges in partisan elections.

"A fair and impartial judiciary is absolutely fundamental to a properly functioning business and economic climate," according to Justice O'Connor.

The judicial system needs judges with the courage to decide against the majority; judges that are appointed for their merit are more likely to have that courage.

Healthcare Compliance Training (A-Z)

2009-02-04T09:25:00.000-08:00

What is the True Cost of Healthcare Fraud - Part IV

2009-01-27T07:34:00.000-08:00

The True Cost of HealthCare Fraud - Part IV
By Dr. Tom Rhudy

When assessing the true cost of healthcare fraud, one must fairly assess efforts expended to breach a fiduciary duty incumbent upon any entity upon which the State bestows its imprimatur, granting a "quasi-governmental" status (e.g., Allstate Insurance, National Insurance Crime Bureau, etc.).

Were competent Healthcare Compliance training to be implemented for all Allstate employees, and a bona fide Healthcare Compliance Officer given authority to enact applicable policies and procedures, one cannot help but wonder, "How much fraud is transacted each and every day, and neither recognized nor reported?" As Goethe said, "The eye only sees what the mind knows."

The "Good Hands People"

Date: 12-11-2008
Case Style: Fred Klecka v. Allstate Insurance Company
Case Number:
Judge:
Court: 150th District Court, Bexar County, Texas
Plaintiff's Attorney: Gravely & Pearson LLP, San Antonio, Texas
Defendant's Attorney:

Description: A San Antonio jury awarded almost a $1 million verdict against Allstate Insurance Company in what attorney Matthew Pearson termed a case where his client was forced to choose between his freedom or his job.

Fred Klecka, a former Allstate special investigation unit (SIU) adjuster uncovered fraudulent claims handling by a co-worker that occurred over six years and involved more than $1.3 million. The fraudulent activities led to a criminal investigation conducted by the FBI."

Our client was told not to cooperate with the FBI or he could lose his job. He chose to disregard the illegal instruction and continued to assist the FBI," Attorney Marc Gravely, Pearson's partner, said after Monday's verdict in the 150th District Court of Bexar County.

Klecka helped the FBI with their investigations of Roland Villarreal, an Allstate contractor, and Chandler Bruton, a claims adjuster. Both were convicted two years ago in federal courts for insurance fraud."

I appreciate the fact that the jury recognized that our client was wrongfully terminated. However, I am especially gratified that the jury decided to punish Allstate for their conduct," Pearson said. " Hopefully, this will prevent another Allstate employee from being placed in the same dilemma."

The jury awarded Klecka $373 thousand in compensatory damages and another $500 thousand in punitive damages.

SOURCE: Gravely & Pearson LLPfor Gravely & Pearson LLP Matt Scherer, 210-325-4130 mattscherer@gmail.com

Outcome: Plaintiff's verdict for $1 million.

Sadly, $1 million is chump-change to Allstate. After spending three more years to have the Appeal heard, and spending hundreds of thousands of dollars on additional legal-fees, the Decsion loses its luster. Nevertheless, Fred Klecka is an individual worthy of our respect and admiration if, as is suggested by this Decsion, he refused to bow to Allstate's efforts to interfere with a lawful investigation into Allstate's activities.

There can be little doubt that the "Good Hands People" will crush any individual who interferes with its bottom-line. Congratulations, Mr. Klecka!

About the Author:Dr. Tom Rhudy is licensed as both an Attorney and Doctor of Chiropractic in the states of Texas and Missouri. While serving as both an Attorney and Doctor of Chiropractic, he has worked closely with law enforcement, insurance carriers, administrative agencies, the FBI, US Attorney's Office, the US Postal Inspector's Office, and healthcare providers in the prevention, investigation, and prosecution of healthcare fraud. For the past 20+ years he has devoted most of his efforts toward educating and assisting providers in the development of healthcare treatment and compliance programs and prevention of healthcare fraud and abuse, making every effort to improve the quality of care and representation provided to patients.

Now you may receive his FREE 10-STEP QUICK-START COMPLIANCE GUIDE created to minimize healthcare fraud and abuse my completing the form below:

What is the true cost of healthcare fraud?

2009-01-20T05:38:00.000-08:00

Are there any secrets remaining regarding the True Cost of Healthcare? It is currently estimated that healthcare fraud accounts for an estimated 100 billion dollars per year in the United States alone!

Healthcare fraud is putatively increasingly a reason that health care costs continue to rise. Unnecessary and fraudulent treatments are being submitted to payer organizations daily, if not hourly. Healthcare fraud has become a huge business in North America today.

Increasingly, health insurance organizations, as well as consumers, are looking at new ways to detect, investigate and prosecute anyone submitting fraudulent health care claims.

In 2000, Americans were spending a staggering 1.3 trillion dollars per year on healthcare! As inexorably as night follows day, when that much money is at stake, the unethical among us seek their personal benefit at the cost of those around them.

What percentage of the $1.3 trillion is spent on fraudulent billing? The truth is, nobody truly knows!

The IRS estimates that between 3 and 10% of healthcare dollars (i.e., $39 billion) may be fraudulent. Independent review organizations, if truly independent, play an important role in helping healthcare fraud special investigative units ("SIU") investigate and determine whether claims are legitimate, whether chart notes support a legitimate case and whether medical necessity is associated with a case.

However, with Billions of dollars at stake for SIU employers (i.e., insurance companies), is it safe to conclude that so-called "independent review organizations" have clean hands? Not very likely!

The same human nature that leads to healthcare fraud permeates the SIU investigator and the "independent review organization." In displays of prosecutorial bravado, too frequently, the innocent are greatly inconvenienced, falsely accused, or even wrongfully convicted.

We all agree, something should be done. The question is, "What should be done?"

Frequently, federal investigators and prosecutors typically rely on a heavy and injudicious hand. The strategy appears to be to make examples of individuals, rather than bring about systemic change, which would be inconvenient and difficult.

What are the types of fraudulent activities that the dishonest Physicians and healthcare providers are known to engage in? The activities include,

• Up-coding/Upgrading (billing for more than actual service provided)
• Providing and subsequently billing for treatments that are not medically ecessary
• Scheduling extra visits for patients
• Referring patients to another physician unnecessarily
• Billing for services to accompanying family members
• Ordering unnecessary tests

Providers often engage in such practices, ignorant of the fact that such activities may trigger fraud investigations. What can providers do when they become the target of a healthcare fraud investigation?

There are several steps providers should take when they become the target of a healthcare fraud investigation. There are 10 steps providers should take:

1. Determine whether the action is civil or criminal. There is a huge distinction. In a civil action, if you lose, you may have to pay monetarily. In a criminal action, if you lose, you may go to prison.

2. Do not shred documents that you now suspect are incriminating.
Although it seems counterintuitive, do not commence a shredding-campaign. Providers frequently fail to realize that patients’ files are often the “crime scene”. By the time you either are made aware of or suspect that you are a target, the incriminating documents are in the investigators’ hands.

3. Determine whether you are a “target” or a “subject” of an investigation.
Frequently, investigators are working closely with prosecutors months, if not years, prior to identifying the “target” of an investigation. If you are a “subject” of such an investigation, this suggests either that the investigation is in an early stage, i.e., information-gathering, or you are a conduit to the “target”. If you are a “target,” seek consultation with someone knowledgeable in health care law without delay.

To see steps 4-10, complete the form below and receive your FREE 10-Step Quick-Start Guide to an effective HealthCare Compliance program.

Your Blood Pressure Medication May be Promoting High Blood Pressure & Heart Disease

2008-10-16T08:51:00.002-07:00

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

Your Medication May Be Causing Malnutrition

2008-10-16T08:51:00.001-07:00

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

Chiropractic Fraud - Perception Vs Reality

2008-10-16T08:49:00.000-07:00

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

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Criminals Who Happen to Be Doctors

2008-10-16T08:48:00.002-07:00

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

TENS Increase Your Profit Margin?

2008-10-16T08:48:00.001-07:00

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

Health Care Compliance, Buyer Beware

2008-10-16T08:47:00.001-07:00

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

Investigating Chiropractic Fraud

2008-10-16T08:46:00.001-07:00

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

The Next Generation of Multi-Discipline Practice Fraud

2008-10-16T08:45:00.001-07:00

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

Investigating Health Care Fraud

2008-10-16T08:44:00.001-07:00

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

Therapeutic Procedures - Explode Your Practice

2008-10-16T08:43:00.000-07:00

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

Health Care Fraud - The Costly Deception?

2008-10-16T08:42:00.000-07:00

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

9 Biggest Mistakes Health Care Providers Make That Result in Surprise Visits From Fraud Investigator

2008-10-16T08:41:00.000-07:00

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

Are Carpal Tunnel Syndrome Exercises Really Effective?

2008-10-16T08:39:00.001-07:00

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

What is Causing Your Carpal Tunnel Symptoms?

2008-10-16T08:34:00.000-07:00

Carpal tunnel syndrome and its causes can be quite controversial at times, depending on who you listen to! For many patients the actual cause of their carpal tunnel syndrome is unknown, however, many feel it is due to repetitive hand activities at work or play. Some studies have shown that increased pressure across the wrist or (carpal tunnel) from repetitive and or awkward wrist movements may increase the chances of getting carpal tunnel syndrome (CTS) in some people. While other studies have shown that medical conditions such as diabetes, hypothyroidism and obesity just to name a few, puts a person at a greater risk. And even more so if they have one or more of these conditions coupled with repetitive hand or wrist activities.

Really almost any condition that makes the carpal tunnel area smaller (i.e. born with a small carpal tunnel, arthritis, wrist fracture etc..) or if a condition makes the things (i.e. tendons, tissues) inside the carpal tunnel larger (by inflammation or swelling)...all these things can lead to carpal tunnel syndrome as more pressure is put on the median nerve as it passes through the carpal tunnel area of your wrist.

We also know that genetics can play a role in who gets and who doesn't get carpal tunnel syndrome. From XRAYS and MRI studies we now know that some people are just born with smaller carpal tunnels than others, so they may get CTS quicker or easier than someone else. The shape and dimension of your wrist may put you at risk for getting carpal tunnel syndrome.

Learn about the wrist exam that most Doctors don't know about called the Square-Wrist sign.

http://www.carpal-tunnel-symptoms.com/square-wrist-sign.html

But remember, it can also depend on your medical conditions, occupations and hobbies as well as to whether you actually will get carpal tunnel syndrome.

Since the causes of carpal tunnel syndrome can be due to multiple factors including medical conditions, it is important to talk with your Healthcare provider about your overall health and wellness status to see if you have any of these diagnoses or risk factors, so you can be treated appropriately and most importantly get better so you can move on with your life!

Joe Shaw PA-C

Board Certified and Licensed Healthcare Provider gives you the facts about carpal tunnel syndrome

http://www.carpal-tunnel-symptoms.com

Article Source: http://EzineArticles.com/?expert=Joe_A_Shaw

Why Your Diet May Not Be As Rich In Iodine As You Assume

2008-10-16T08:33:00.000-07:00

The trace mineral iodine is well known for its crucial role in enabling the body's manufacture of vital thyroid hormones, but it is also important for the health of the immune system and for optimal brain function. It is widely believed by many authorities that iodine deficiency should never be seen in the affluent West, although this problem affects millions throughout the developed world.

Some nutritionists argue, however, that this conventional view is too optimistic, because the content of all minerals in foods is heavily dependent on the mineral content of the soil from which those foods are derived. The assumption must therefore be that the continuing de-mineralisation of farm soils has led to a reduction in the amount of dietary iodine commonly consumed.

Fish and other seafood, however, remain a relatively rich source because these ocean creatures concentrate the sea's iodine in their flesh. Though not commonly eaten in the West, seaweed, or kelp, is also an excellent source of iodine for this reason, and is readily available in the form of a dietary supplements. Dairy products and certain meats may also be a good source, particularly where iodine is routinely added to farm animal feed. But in countries, including most of Western Europe, where animals are grazing fields growing on iodine depleted soils, levels are likely to be much lower.

So even in the West, those not including fish or seafood in their diets, and not using iodised or sea salt, may be at real risk of deficiency. In an effort to compensate for low levels of dietary iodine, the mineral has been routinely added to ordinary table salt in the US for many years. But the practice is not as common in the UK and other European countries, where specially iodised or natural "sea-salt" has been marketed more as a luxury alternative. The problem of insufficient dietary iodine has been compounded on both sides of the Atlantic, however, by increasing concern about the possible adverse health consequences, particularly high blood pressure, of excessive salt intake. Many nutritionists, however, regard these fears as exaggerated, and believe that any such potential problems are far less serious than the consequences of an insufficiency of iodine, and may be easily resolved by the use of the low sodium salt alternatives available.

Iodine, however, cannot in any case be regarded as a luxury. Its essential function lies in the production of the vital thyroid hormones; thyroxine, sometimes known as T4, and tri-iodothyronine, or T3. And as is well known, these hormones are crucially important in ensuring a healthy metabolic rate and the release of energy from food; so an underactive thyroid gland is commonly the villain in cases of excessive weight gain, particularly where this of sudden onset, and in cases of difficulty in losing weight even when following a sensible reducing programme. A healthy thyroid gland is also crucial for the optimal functioning of the immune system.

But perhaps even more importantly, iodine deficiency is also known as a major cause of avoidable brain damage; a problem which the World Health Organisation has estimated to affect an astonishing 50 million people worldwide. Sadly, many of these cases occur in children whose mothers were iodine deficient in pregnancy, resulting in a condition of severely retarded brain development known as congenital hypothyroidism, or "cretinism". Even where such catastrophic consequences are avoided, iodine deficiency in childhood may also have serious effects on the developing brain, leading to low energy and motivation for learning, and measurable impairment of IQ scores.

Since 2001 the Food and Nutrition Board of the US Institute of Medicine (FNB) has prescribed a Recommended Dietary Allowance for iodine of 150 mcg for all individuals over 14, rising to 220 mcg for pregnant women and 290 mcg for those breastfeeding. Somewhat confusingly, however, an excessive consumption of iodine is also associated with a malfunctioning or enlargement of the thyroid gland, as well as mouth ulcers, headaches and gastric upsets, and the FNB therefore advises an upper safe limit for daily iodine consumption of 1,100 mcg for adults. Most people eating a conventional Western diet are unlikely to exceed this level.

With the possible exception of pregnant and breastfeeding women, people in the West who use liberal quantities of iodised salt as a regular seasoning are unlikely to need further supplements. But many commercial multi-mineral preparations contain iodine in reasonable quantities, usually in the form of potassium iodide, and whilst not perhaps strictly necessary, such supplementary doses will do no harm and may be regarded as a useful insurance policy given that, like all minerals needed by the body, iodine functions best in the presence of adequate supplies of all the others. And it should be particularly noted in this context that the effects of any deficiency of iodine may be intensified by any deficiency of selenium, iron or vitamin A.

About The Author

Steve Smith is a freelance copywriter and journalist with a particular interest in health and wellness.

Find out more at http://www.sisyphuspublicationsonline.com/LiquidNutrition/Iodine.htm

Cancer Or Is It Christ In You?

2008-10-16T08:31:00.000-07:00

They call “cancer” the big “C” word. Is it really? I beg to differ as a Christian.

I hope the information in this article will give hope to you who have been given no hope because a doctor has diagnosed you with cancer.

I would hope you would rather focus your attention on “Christ” no matter what stage of cancer has been diagnosed and no matter whether you are a Christian or not. “Christ” should be the big “C” word in your life right now and there is nothing to fear when you use it. What does it mean? It means, “The Anointed One” and refers to His anointing. Jesus is the Christ, “The Anointed One”. And His anointing is burden removing, yoke destroying power. There is no type of cancer that can stand up to the anointing of Christ, the Anointed One. And contrary to some, He is still anointed today to remove all curses, including cancer, from all people and still wants to “heal them all” just like He did in the Bible. Hebrews 13:8 Jesus Christ the same yesterday, and to day, and for ever. KJV This revelation of Christ’s anointing should rid us of all fear of cancer. Many just need to be given the revelation of Christ’s anointing and that it is free and available to all just like chemotherapy or radiation is readily available. The chemotherapy and radiation are costly but the anointing is free and available to all.

I know there are many questions that arise when we talk about healing and so I hope my answers from the Word of God will convince you that Christ and His anointing is available to you just as easily as the chemotherapy or radiation.

What is cancer anyway? Cancer is a disease. So according to the Bible since it is a disease then cancer is a curse. If you look at Deuteronomy 28, you will find all the curses that are a result of not keeping the Law of Moses and cancer being a disease is included.

Now since cancer is a curse, you as a Christian have been redeemed from all the curses listed under the Law according to Galatians. How did that happen? Galatians 3:13-14 Christ hath redeemed us from the curse of the law, being made a curse for us: for it is written, Cursed is every one that hangeth on a tree:14 That the blessing of Abraham might come on the Gentiles through Jesus Christ; KJV You see Christ actually purchased your freedom from cancer or any other curse when He became a curse and hung on His cross. See, His sacrifice was for your total man, spirit, soul and body.

Some believe God gave them cancer. Did God give you cancer? If He did, then Christ Jesus was cursed for no reason for you and you might as well take Galatians 3:13 out of your bible. But I don’t want to take Galatians 3:13 out of my bible because I have received healing by taking that promise as my very own and you can also.

If you believe God gave you cancer, my question to you is; where would God get cancer to give it to you and why would He give it to you? There is no cancer in heaven for God to give it to you and it would be contrary to the bible for God to give you a curse. James 1:17-18 Whatever is good and perfect comes to us from God above, who created all heaven's lights. Unlike them, he never changes or casts shifting shadows. 18 In his goodness he chose to make us his own children by giving us his true word. And we, out of all creation, became his choice possession. NLT God never changes. His desire to bless you never changes.

If He put cancer on you He would be putting a curse on you and therefore He would be ignoring Galatians 3:13 and Jesus becoming a curse for you so that you could receive the blessing.

Some say cancer and other bad things happen to you because God is punishing you for your sins or is trying to teach you something or make you a better witness. Why would God give you cancer or any other bad thing to punish you for your sins; when as a Christian, God has punished Jesus for all of your present sins, past sins, and even our future sins from the foundation of the earth.

Ephesians 1:2-7 Grace be to you, and peace, from God our Father, and from the Lord Jesus Christ. 3 Blessed be the God and Father of our Lord Jesus Christ, who hath blessed us with all spiritual blessings in heavenly places in Christ: 4 According as he hath chosen us in him before the foundation of the world, that we should be holy and without blame before him in love: 5 Having predestinated us unto the adoption of children by Jesus Christ to himself, according to the good pleasure of his will, 6 To the praise of the glory of his grace, wherein he hath made us accepted in the beloved. 7 In whom we have redemption through his blood, the forgiveness of sins, according to the riches of his grace; KJV

Why would God give you cancer to teach you something? Would you give your children something bad to hurt them or destroy them so they could learn something? Certainly not. Being a good parent you would sit them down and tell them not only not to do some thing again but you would show them why it is wrong and the consequence of it. And anyway, teaching your children by abuse, don’t people get arrested for child abuse in our society? Then how could God not be guilty of abuse if He put cancer on His children to teach them something or for any other reason and how could He not be guilty of not keeping His Word, especially Galatians 3:13.

Here is what the Word of God says about correction from God to His children: 2 Timothy 3:16-17 Every Scripture is God-breathed (given by His inspiration) and profitable for instruction, for reproof and conviction of sin, for correction of error and discipline in obedience, [and] for training in righteousness (in holy living, in conformity to God's will in thought, purpose, and action), 17 So that the man of God may be complete and proficient, well fitted and thoroughly equipped for every good work. AMP

So our correction as a child of God comes from the Word of God. The Word of God instructs, reproves, convicts of sin (Does not condemn by the way.), corrects of error, disciplines and trains in holy living and conforming to God’s will. That is why we need to read it and meditate it daily so we aren’t taken advantage of by our ignorance of God and His Word and His love for us as His children.

Who in his right mind would want to listen to someone testify of their great God giving them cancer and want to have any thing to do with Him?

Would you want your children tell their friends how you did bad things to them in order to teach them? Certainly not. And neither does God because He is not a child abuser for He is the best Father this planet will ever know anything about and from which all fatherhood should be copied.

And how can having cancer make a good witness of God when most sick with any kind of sickness or disease (especially cancer) are not able to be a good witness because of the pain and suffering. The pain and suffering are also a good indication it is not from Father God.

Why did Jesus, the Christ, come to this earth for any way? Here are some scriptures I think will answer that question:

John 10:9-11 The thief comes only in order to steal, kill, and destroy. I have come in order that you might have life — life in all its fullness. 11 "I am the good shepherd, who is willing to die for the sheep. TEV

1 John 3:8 The reason the Son of God was made manifest (visible) was to undo (destroy, loosen, and dissolve) the works the devil [has done]. AMP

Jesus came to destroy cancer, sickness, disease and all curse and that is what you see Him doing in the Gospels. And Jesus told us He only did and said what the Father told Him to say and do and it was the Father through Him doing works of “healing and delivering them all”.

Do you think if Adam and Eve had not sinned, would God use sickness, disease or calamity to teach them? Certainly not and neither does He use them to teach us, His children, whom the Bible declares He loves us as much as He loves Jesus. Did He teach Jesus with cancer, sickness, disease, or calamity? Certainly not. People are put in prison for child abuse. God is not a child abuser.

Here are the facts & the truth about Cancer vs. Christ:

Cancer is a disease.

Christ is the Anointed One who destroys all disease in your body, including cancer.

Cancer is not the big “C” word.

Christ has been given a name above all names, the name of “Jesus”, which includes cancer. The name of Jesus has been given to you to speak and see cancer leave your body now!

Cancer is evil and not God sent.

Christ is God sent to be your Savior from cancer now!

Cancer is life threatening.

Christ has brought you abundant life to the full till it over flows.

Cancer comes to kill, steal & destroy.

Christ came to destroy the works of the devil which includes all diseases and that means all evil works of cancer in your body now!

Cancer is a fact.

Christ is the way (Your way out of cancer.), the TRUTH (The truth, He has redeemed you from cancer.), and the LIFE (How can cancer live in your body where Christ, God, Life Himself lives?)

Cancer can be diagnosed.

“In Christ” is really who God and His Word says you are and what you have in this life. (See “In Him” scriptures on my website, so you can declare who you are “in Christ” and what Christ has made you to have.)

Cancer checkups are what they recommend.

In Christ, you are told to look continually into the perfect law of liberty, the Word of God;primarily the Book of Acts through Revelations and make a checkup daily of the blessings of Christ on your body and do no checkups for the curse from which Christ has purchased your freedom. (James 1:22-25)

Years ago I was doing a check on my body for lumps as recommended and the Holy Ghost asked me, “What are you checking for? Are you checking for the curse? You shouldn’t be looking for the curse on your body but for the blessing Jesus purchased for you.”

I have found so many times that woman especially, if the enemy can get a breast or even both with cancer he will get the female organs and on and on. If he can place fear of cancer in our minds that is where the seed for cancer is first planted and then manifested in the body if we meditate on it long enough, start believing it and speaking it; like, “Cancer runs in my family so I probably will get it,” or other words to bring it to pass in our lives. That is why we need to fill our minds and mouths daily with whom and what Christ has made us to be and what He has purchased for us.

Here is your hope of never having cancer or hope when the doctor speaks the word “cancer” to you. If you will meditate and speak these words of hope every day, as many time as you take treatments or medication then you will receive the hope inside of you that will remove all fear and allow the Anointed One and His anointing to work.

Let’s make this confession of our faith in Christ and His anointing every day:

I am redeemed from all the curse of the Law since Jesus became a curse for me. I will not tolerate these curses for they are not in my new covenant in Christ Jesus established in the righteousness of Jesus. I do not allow the curses of the Law to come on my body. Christ Jesus has redeemed me from destruction and perishing before my time. This new covenant has given me the blessing of living a long, full and satisfying life. Christ Jesus has redeemed me from all pestilence which bring agonizing death, including cancer. Christ is the big “C” in my life and not cancer. Christ Jesus has redeemed me from tuberculosis, cancer, progressive wasting of my body, fever, inflammation, and effects of draught, decay, and mildew. Christ Jesus has defeated my enemies and I am completed in Him. Christ Jesus has redeemed me from boils, tumors, malignant diseases causing a discharge, scurvy (bleeding gums and livid skin patches), scabies, hives, rashes and all skin diseases, which cause an itch. Christ Jesus has redeemed me from going crazy because of what I see going on around me. Christ Jesus has redeemed from every curse that tries to come on me and overtake me so that I am destroyed. Christ Jesus has redeemed me from all sickness and plague having a long duration. Christ Jesus has redeemed me from every disease that is in the world. Christ Jesus has redeemed me from all sickness that is known and all sickness that is not known. Christ Jesus has redeemed me from every sickness that has ever been on the earth and ever will be on the earth. Christ Jesus has redeemed me from exhaustion in my heart, my eyes, my mind, and my spirit. Christ Jesus has redeemed from all the curses now! Because of Christ Jesus none of these will come on my body. My life is now in Christ Jesus, my Lord, and I am forever set free from all of these curses now on this earth! I now look for the blessing of Christ on my body.

I personally know this works. My family and I for over 30 years have not had a doctor’s appointment, hospital stay or had to take medication; we just took the Word of God for our healing. And really the more you know the truth of the Word of God, like myself, you will find that you will have very little symptoms come on your body.

So it is Christ in you who is your hope of glory not only in the life to come but also in this life. Live in Him, vitally connected to Him in your every day life. Your intimate relationship with Him filled with love and acceptance is where you will stay free from things that would come to kill, steal and destroy in your life. His love frees you from fear, worry, stress, rejection and condemnation that really are the killers in this day in which we live. A good remedy is just to spend time with Him enveloped in His love, a day would be much to your advantage.

I have listed on my website scriptures and confessions to help you stay strong in your covenant right of divine health and also to restore to you what Jesus purchased for you. I agree with you for your deliverance from cancer and that you continue to live in divine health. I also offer to you on my website a book of Doddie Osteen’s, “Healed of Cancer” to encourage you. God bless you, in Jesus’ name.

About The Author

Janie Baer has produced a CD called God’s Spoken Word and her website http://www.godswordalive.com offers products to help Christians use Bible scriptures in every day living finding the secret power of god’s word and to help find the unconditional love of Father God. Janie also has a blog, http://www.godswordalive.com/blog. Also on her site is Kingdom of God Prosperity Bookstore which offers bibles, audio bibles, music cds, music dvds, Children books & dvds, Christian books, Christian games and other products to help incorporate the Word into your life. She has also recently added Bible scriptures and confessions for healing and health, prosperity, Father God’s Unconditional love and continues to add more all the time. She has applied these healing scriptures with her family for over 30 years and as a result they have not had a doctor, hospital or medical bill in all those years. They have just taken the healing Bible scriptures as their medicine as was written in Proverbs 4:22.

Everything You've Always Wanted To Know About HIPAA And FERPA

2008-10-16T08:30:00.000-07:00

Consider this question. Say the mother of a 22-year old student that you have treated requests to see her daughter’s medical records. The Bursar’s office confirms that the student is listed as a dependent for tax purposes. There seems to be no urgent reason for such a release and the student does not wish to give her mother access. How would you protect the privacy of her information?

Situations such as this one that require knowledge of privacy laws to resolve successfully are all too common in the average student health center, yet the acronyms HIPAA and FERPA tend to strike fear into the hearts of the staunchest of college health professionals. So much has been written anecdotally on the subject of how complicated and unspecific these laws are that some may be surprised to find that according to legal professionals, the intersections between the laws are generally clear-cut. This article aims to explain which laws apply to you and what you can do to avoid the headaches that ensue from a conflict between your principles as a care provider and the law.

Six golden rules of privacy law

* FERPA never applies to non-students
* FERPA only applies when the student’s medical records are released
* HIPAA doesn’t apply to records covered by FERPA or to student “treatment records”
* Even if you treat non-students, you’re not bound by HIPAA unless you perform electronic transactions.
* Student health and counseling centers that do perform electronic transactions for non-students only have to abide by HIPAA for those transactions.
* State laws are applicable whether or not other federal laws apply

This is how these rules break down.

RULE 1: FERPA never applies to non-students

RULE 2: FERPA only applies when the student’s medical records are released

The Family Educational Rights and Privacy Act (FERPA) is the older of the two federal privacy laws. Enacted in 1974, one aspect of its governance is the privacy of educational records. There is a popular myth circulating that student medical records fall under the FERPA’s umbrella term “educational records”. In fact, FERPA specifically excludes the treatment records of students in higher education from its definition of educational records (see USC 20, 1232g for a complete definition). It also excludes employees of an educational institution if they are not students. FERPA does come into play, but only if the records are released to someone outside the health center, whether that is the student, their parents, their professors, or another health provider outside the university, at which point they become “educational records” rather than treatment records.

It is important to note that it is not the request for the release that brings FERPA into effect. Many student health professionals believe that if a request to see the records is made that is in accordance with FERPA guidelines, they have to release them or be in violation of FERPA. Not so, says Kristine Dunne, BA, EdM, JD, an associate at the Washington, D.C. office of law firm Arent Fox, LLC.

“It's the release of the records that triggers FERPA,” she explains. “There are no rights extended under FERPA to those medical records until such time as they have been made available to someone other than the treating health professionals, at which point the FERPA protections of student records kick in.”

Applying this to the example at the beginning of the article, if state law doesn’t require you to release the student’s unreleased medical records to her mother, you are under no legal obligation to do so without a court order. Similarly, even if you think a professor may have a “legitimate educational interest” in requesting a student’s unreleased medical records, you still don’t have to release them.

FERPA is just one part of the puzzle, however. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is another relevant law that seeks to be the national privacy standard in health care. It was updated in 2003 to take into account the trend toward automation and electronic record-keeping. These privacy guidelines have been well publicized and generally uphold the kind of patient confidentiality that most health care providers are comfortable with and there has therefore been a widespread trend in health centers to apply these standards to student medical records, even if they are not legally required. It is important to realize, however, that while its principles of privacy and confidentiality are excellent, in most cases, compliance is not required by law.

RULE 3: HIPAA doesn’t apply to records covered by FERPA or to student medical records which are made, maintained, or used only in connection with the provision of treatment to the student, and are not available to anyone other than persons providing such treatment.

RULE 4: Even if you treat non-students, you’re not bound by HIPAA unless you transmit health care information in electronic form in connection with the submission of claims for payment.

HIPAA’s definition of protected health information (PHI) specifically excludes education records covered by FERPA and the treatment records of students in higher education as defined above. Dunne explains that the goal of this exclusion is simplification.

“If student medical records were subject to HIPAA, there would be two completely different schemes – up until the health center released the record, it would be governed by HIPAA, and when it had been released it would be governed by FERPA,” she says.

This was apparently considered unworkable by Congress, hence the blanket exception that HIPAA makes for any kind of student medical records. However, many student health and counseling centers also treat non-students, and this is where it starts to get a little bit trickier. To be considered a “covered entity” (i.e., bound by HIPAA), your health center must electronically transmit health information in connection with a “HIPAA transaction”. More detailed information on what constitutes a HIPAA transaction can be found in this primer released by The American Council on Education, but essentially it is any administrative or financial task carried out in the course of health care that transmits PHI. If you don’t perform electronic transactions, you don’t have to comply with HIPAA.

RULE 5: Student health and counseling centers that do perform electronic transactions for non-students only have to abide by HIPAA for those transactions.

Usually, every transaction of “covered entities” has to be bound by HIPAA standards, even if they are not all electronic transactions. However, because of the intersection with FERPA, these health centers are able to be bound by HIPAA just for the non-student transactions.

RULE 6: State laws are applicable whether or not other federal laws apply

With all the fuss about HIPAA and FERPA, don’t forget about your state’s laws concerning privacy. In some cases, state laws are the only ones that will apply to student medical records, but even where HIPAA or FERPA apply, state law is still relevant. Despite the fact that HIPAA is a federal law, it bows to state law in those cases where state law is more stringent. Arent Fox Associate Richard Liner, BA, JD, MPH, elaborates:

“HIPAA has an enormous pre-emption problem because it sets a floor and not a ceiling for health care privacy. Congress only established a minimum for protecting patient information. If a state’s laws or regulations are more stringent than HIPAA in their protection of patient health information, then covered entities must follow state requirements.”

This may conjure up ideas of conflicting laws, but Arent Fox counsels that generally, state laws are more specific and will very rarely conflict directly with HIPAA or FERPA. If more than one law is applicable, generally the more stringent requirements will apply. When in doubt, consult counsel before taking action.

Knowing the theory is one thing, but applying it can be a lot more complicated. FERPA requires the student to give written, dated permission before his or her student records information is released – even to other health care providers outside the university, which is a source of frustration for many. But the same information can be released, unauthorized, to school officials who have a “legitimate educational interest”. Similarly, FERPA allows unauthorized disclosure in an emergency, if it is “necessary to protect the health or safety of the student or other persons”. Dunne counsels to rely on common sense to interpret these terms, and to consult counsel early in the process. No law can specifically cover every eventuality; the burden of responsibility and interpretation must, through necessity, rest on the care provider.

This responsibility weighs all the more heavy because schools are concerned about penalties for breaching FERPA. If the Family Policy Compliance Office (FPCO) found a pattern of violations of FERPA with no obvious attempts to follow the guidelines, it could result in a removal of federal funding. However, it is important to know that individuals cannot be prosecuted for a FERPA breach and individual students cannot sue for damages for such a breach. Schools should carefully develop, implement and maintain compliance oversight with regard to these important privacy laws in order to prevent unlawful release of student records. Likewise, if your school treats non-students, files electronic claims and is bound by HIPAA for those transactions, you should make sure that HIPAA protections are implemented, even though a HIPAA violation may not – for now – result in a fine being imposed. Liner explains:

“In the vast majority of cases where there’s found to be a violation of HIPAA, there is what’s called an ‘administrative resolution’, which generally means the mistake wasn’t intentional and the organization voluntarily agrees to take appropriate remedial action.”

No civil fines for violations of HIPAA have been imposed so far, although Liner warns that is likely to soon change.

Although information on the triumvirate of privacy laws has always been available to those who know where to look for it, there is also a wealth of partial and incorrect information available on the Internet that has muddied the waters for those health professionals attempting to do a little research on the laws that apply to them. Dunne and Liner counsel that you should speak to a professional who knows the law in your state and the ins and outs of FERPA and HIPAA if you are worried about misinterpretation of the law. Even if you know the basics, state laws vary greatly and knowing the details of how the three laws intersect will allow you the greatest leeway to interpret them in a way that is consistent with your ethics.

“It is complicated,” sympathizes Liner. “Talk to the privacy officer within the university, if there is one. There are also a few government Web sites that are really good in terms of user-friendly guidance to help people navigate through the more basic pitfalls.” For instance, the Office of Civil Rights, the enforcement agency for the HIPAA privacy standards, offers tremendously helpful information and FAQs on its Web site.

“Consult with your legal counsel to ensure you’re interpreting and applying the law correctly,” adds Dunne. “And be clear to those who use student health center services, especially students, about the laws that apply.”

About The Author

Kristine Dunne, BA, EdM, JD and Richard Liner, BA, JD, MPH, Associates of the Washington, D.C. office of law firm Arent Fox, LLC. This article appeared previously in NuesoftXpress ( http://www.nuesoftxpress.com )

Would you know if you were the target of a health care fraud investigation?

2008-10-12T18:09:00.000-07:00

Would you know if you were the target of a health care fraud investigation?

Find out if you are a health care fraud target.

Would you even know if you were the target of a healthcare fraud investigation?
Discover whether you are a healthcare fraud investigation target.

Healthcare Fraud

Are You the Target of a Healthcare Fraud Investigation?

Would You Even Know?

Reimbursement Denials May Be Your First Clue That Your Files Have Been Flagged!

If Your Files Have Been Flagged, Brace Yourself –A Storm Is Brewing!

Dear Doctor:

Healthcare providers across the country are being targeted for healthcare fraud investigations. Many of those providers are clueless of this fact!

Are your own actions causing you to be targeted?

Do you do one or more of the following?

You accept what the insurance carrier offers, without question.

You work with 3rd- party liability carriers and accept what your patients give you once they receive settlement, and accept your patient’s account of settlement negotiations.

Your patient retains an attorney to handle a 3rd-party liability claim, and you accept the attorney’s offer of settlement without question.

You work consistently with a limited number of external providers (e.g., physicians, surgeons, neurologists, etc.).

You don’t bother to read the Explanations of Benefits (“EOBs”) in which the insurance carrier identifies the reasons for denial.

You don’t bother to read peer reviewers’ reports.

You don’t bother to respond to the peer reviewers’ reports, considering them merely a nuisance and cost of doing business with insurance carriers.

You either don’t bother to read, or don’t receive, Controverting Affidavits in which both reasons for denial are reported and aberrant practices are alleged.

You don’t bother to respond to the Controverting Affidavits in which reasons for denial are reported, considering them merely a nuisance and cost of doing business.

You don’t bother to respond to Controverting Affidavits in which aberrant practices (e.g., unbundling of services, medically unnecessary services, medically unnecessary referrals, etc.) are alleged, because you either consider such allegations harmless or you have neither the time nor ability to provide a response challenging such allegations.

If the answer is yes, then you need to take action immediately.

While you can rationalize to yourself that these issues are just the cost of doing business, a nuisance and can be ignored, the consequences can be disastrous.

By not sticking up for yourself you are looking an awful lot like someone who is afraid to challenge the system…maybe because of guilt…at least that is what the carriers want to believe.

Here are some real life examples

Example #1

Practice:

Medical neurologist billing for neurological evaluations, as well as electrodiagnostic services, when those services were billed by a physician located hundreds of miles away from the lay-technicians the neurologist employed, at the very time his lay-technicians were performing those services.

Consequence:

Providers, to include those providers splitting fees with the neurologist, and technicians were convicted of felonies.

Example #2

Practice:

Chiropractor convinced husband and wife that the chiropractor had cured the HIV+ positive husband, and that the husband and wife, who had obtained permission from their church-council to engage in protected-sex, a practice prohibited by that community, could engage in unprotected sex.� The wife and baby subsequently contracted HIV.

Consequence:

Suspension of license.

Example #3

Practice:

Physician allowing a lay-individual to direct physician’s treatment, etc.

Consequence:

Loss of license.

What can I do?

What are some of the ways in which you may salvage your practice, license, and freedom if you have become the target of a healthcare fraud investigation?� Here are a few examples:

Develop a healthcare compliance program. Do not make the mistake of believing that a sham compliance program will suffice. You are better off having no compliance program than merely using one for window-dressing. The false sense-of-security often proves disastrous!

Develop an audit-response program that effectively addresses deficiencies, both noted and alleged.

Develop a policy for refunds of monies paid in error, when such errors are noted during internal audits.

Develop an effective auditing process, assessing medical necessity and billing issues.

Meet with SIU agents who may have “flagged” your files to identify specific areas of concern.

Develop a Hotline to address issues of concern coming from employees, patients, insurance adjusters, etc.

It may be possible to enter into a Corporate Integrity Agreement between the targeted-provider and investigators.

Retain an attorney knowledgeable in healthcare law. Do not trust your fate to an attorney inexperienced in this arena. Rest assured, the insurance carriers will not!

I have seen the exodus of hordes of providers due the insurance industry’s stranglehold on the healthcare industry, and I have taught literally thousands of providers to fight back.

What should you do now?

If you either know or suspect that you are the target of a healthcare fraud investigation, do not delay seeking a resolution! It is likely that your problem is compounded with each passing day.

If you would like to know whether you either are a target or likely to become the target of a healthcare fraud investigation, I can assist you in analyzing your current practices.

Thomas Rhudy
www.thomasrhudy.com