How Real Health-Care Reform Would Stop the Medical Fraud Machine -- and Lower Your Car Insurance
In one of my past incarnations, I used to be a medical fraud investigator. My job was to catch medical providers and clinic operators who were ripping off insurance companies -- mostly by billing for unnecessary and expensive treatments for fabricated car accident injuries.
The vast majority of the cases I investigated were in the state of New Jersey, where insurance laws meant to protect consumers actually make it a magnet for insurance fraud. There were scam artists from states as far away as Massachusetts who commuted to clinics in NJ after being shut down, it was that easy - and that lucrative.
The scam was usually run in poor urban areas. Personal injury lawyers hired people to drive vans around town, and if there was a fender bender, the driver would scoop up the "victims," take them to the lawyer to sign a contract, and then drive them to the crooked chiropractic clinic.
When you'd look at the patient files (as a representative of the insurance company, I had the right to see the patient files), you'd see rubber-stamping. Every patient had the exact same diagnosis, every patient got the exact same treatment - i.e., just about anything the chiro could bill. Some of them had their secretaries do the "treatments."
I remember one of the crooked chiros (he had a chain, they hardly ever had just one office) had all the people who worked for him snowed. One of his former employees described him to me as "a saint" who really didn't care about money - "I worked for him for five years, and he didn't make enough to give me a raise," she told me.
"Would you be surprised if I told you your doctor was stopped carrying three million dollars in cash to the Cayman Islands?" I told her. "Because he was." (These crooks invariably cultivated flirtations and even relationships with the women who worked for them to keep them from looking too closely.)
You should have seen the look on her face.
Anyway, the client we worked for was one of the very few who actually pursued this kind of fraud. Most insurance companies just look the other way; it's faster and easier. But this is a big part of why your car insurance is so expensive.
Now let's look at something else. Universal health care could be an indirect version of tort reform, because the bulk of personal injury claims are to cover the cost of medical problems incurred and their ongoing treatment. Suppose your injuries were simply covered? What if paying for those things was a moot point, because you always had access to the health care you needed?
Remember, you get a premium discount on car insurance for having health insurance. What if everyone had it?
As you may remember, I've spent almost two years trying to get my ankle taken care of. One of the biggest problems is that I fell out of a tractor trailer and onto my ankle - which meant I had to file the payment claim with my car insurance company instead of simply using my own health insurance.
Unfortunately for me, I didn't incur enough expenses to use up the original auto insurance claim. Now that I've finally gotten a diagnosis and a recommendation for surgery, guess what?
The surgeon refuses to treat me because he'll have to put in two separate claims to get paid.
This system's really crazy. We need to fix it now.
I could use some secretarial "treatment" just about now.
Diabolus est Deus Inversus
I see it everywhere but I have no idea what it means. I thought I knew the internets, but I guess not...
cheek->)O(<-cheek
_______^
mouth, blowing hot air.
Another mystery solved =D
It's this.
Or it's this, but it's just a take on my original offering.
Don't try to confuse the issue with half-truths and gorilla dust.
it's the phases of the moon.
(But my first guess was Home Alone)
Corruption favors the wealthy.
http://www.elfwood.com/~dianae/Pan_And_Selene...
i hope your right.
That is Michelle Bachmann.
"We will find fulfillment not in the goods that we have, but in the good we can do for each other."
Robert F. Kennedy
and that the name was a bit naughty.
But that means lying or bloviating, doesn't it? I thought of it more as when you see something that's just unbelievably stupid or outrageous and you sort of blow out through your mouth "WHOOO" (not saying that word but forcefully breathing it out), and your next words are emphatically whispered: "Jesus Christ!" or some similar expression of frustration and disbelief.
Yes?
YS doesn't blow hot air!!? Must be somethin' else??!! #;}
"Egotism is the anesthetic that dulls the pain of Stupidity" - Frank Leahy
..that dealt with that exact type of fraud. Art imitating Life, Life imitating Art. A bottomless barrel of laughs I tells ya'!
Mickey: "It was an epiphany. Do you know what an epipany is?"
Keoni: "NOT NOW MICKEY!"
Several TV series in the past decades have dealt with this -- I seem to remember a "Quincy" episode from the 1970s that dealt with it!
One shouldn't drink and drive tractors.
Diabolus est Deus Inversus
would anyone drink a tractor?
Welcome to Texas. We do it for fun.
I'm a native, Houston particularly, so yes, I'm aware that we tend to eat anything as long as it's fried.
texas brisket does taste right good.
http://www.youtube.com/watch?v=fxME9TeoxyQ&fe...
Diabolus est Deus Inversus
...real health care reform, the first thing that would happen is that the insurance companies would be relegated to the very minor role of offering supplemental insurance for frivolous electives like vanity plastic surgery. The justice department would have a branch dedicated to bringing healthcare fraudsters to justice. There would be a government regulatory arm to strictly regulate Pharma, like FERC or the NRC.
Trying to reform the insurance companies is about as fruitful as trying to reform a psychopath. an empty exercise.
You might be able to get a private room and a "head" nurse.
Diabolus est Deus Inversus
Is she the one with dirty knees?
It's a he. Enjoy your stay.
(sorry for the homophobic 'joke' - I resented the sexism.)
They both can have dirty knees.
And my brother was a nurse, also. So no one's a phobe here.
It's an old and admittedly sexist joke, though.
Head also refers to the john.
Funny thing though, that latter vernacularism refers both to the washroom as well as a frequenter of courtyard courtesans.
Diabolus est Deus Inversus
is the same, they run you through a patient mill to milk every last medical dollar allowed, never fixing the actual injury "for your own good".
Your liar, er-lawyer gets his and you're out the door.
have something in DC called "The House of Representatives" and a "Senate" which protect them from people who don't want to part with all of their loot.
Maybe we, the people, could get something like that.
WE want to fix it and because a Doctor is reluctant to file two claims, he balks at treating you? You'd think the Doctor, who took an oath to "..first do no harm." would want the same thing. So much so that he would take the issue up with the AMA and then the AMA would lobby (I said a bad word)Congress (hopefully without bribing our trusted, elected officials) to make changes.
We want to FIX it now but we are faced with seemingly crazy people who don't want change because they are afraid of helping their neighbors or because Obama's in the White House or they want to shoot guns at liberals or whatever crazy reason they have today. Maybe the sun came up and the glare blinded them, I don't know. But we do need to fix it!
Mickey: "It was an epiphany. Do you know what an epipany is?"
Keoni: "NOT NOW MICKEY!"
... is that it is a legally sanctioned monopoly. In a nation of over 300 million people you're going to have examples of pretty much everything. However, on balance, the insurance companies don't take the hit on fraud. Not only do many insurance companies not "look the other way" on instances of fraud, they hype it and use it as an excuse to deny or delay many other legitimate claims.
Take a close look at what they are calling "frivolous lawsuits." The look reveals that a suit is frivolous - not because it's a poster child example of fraud - but because the carrier simply does not want to pay the claim or wishes to delay on paying the claim.
There's a time value of money to the the carriers. If they can delay a claim for four years or more, the money gained on the delay can cover substantial portions of the claim. They get to pay people with the interest off the money they should have payed in the first place.
The carriers are more than able to protect themselves from lawsuits that are actually frivolous. They have special laws written by their own lobbies to protect themselves. They have literal armies of lawyers. They can look after their own interests in fighting fraud just fine.
But this isn't about the poor multi-billion dollar insurance companies getting taken advantage of by two-bit shysters. This is about denying or delaying valid claims.
If you follow the money, it's simple arithmetic. The more they deny or delay, the more money they make.
Corruption favors the wealthy.
I've often thought that if the state governments were going to make car insurance mandatory, then they should offer less expensive government insurance. Car insurance companies are like the health insurance companies (only they don't actually kill as many people) -- if you actually use your insurance by filing a claim, then they raise your rates to punish you.
You have the option of NOT driving.
Our 'Culture' has not made that option at all friendly but it is possible.
With health care, your option might be dying.
If you are really sick, that is what the health deniers want you to do. Their profit is maximized by denying care.
statusquObama, change you can only pretend in
Or, as a friend of mine said some time ago, if carrying (and paying for) car insurance is mandatory, then on the flip side, the insurance companies should be required to pay the claims.
but I think most states only require you to have Liability coverage - to pay for the damage/injuries you may cause to others while driving your car.
"Egotism is the anesthetic that dulls the pain of Stupidity" - Frank Leahy
As long as human beings are capable of greed there will always be someone scheming to beat the system. Sadly it seems to get easier for them every day as the bureauracy grows so large it can't keep up with the simple schemes.
Say what you mean. Mean what you say. But don't say it mean.
there's no doubt there's fraud involved in health care and health care insurance. both sides need to have their enemy to justify their own misdeeds. the insurance companies enjoy that strategy of delaying payment by deciding who should pay. the health care insurance strategy DENY...DELAY and DEFEND. for some practitioners i think this sets up the rationale to break the rules/cheat the system because some of them feel wronged/cheated. i'm not saying it's right but i believe it's the one of the outcomes of the current health care insurance model.
Among the many thorns of today there was a rose. The president just awarded the medal of freedom to an amazing array of people. From an elderly Native American to a previous supreme court justice.
Say what you mean. Mean what you say. But don't say it mean.
and pain endured by hundreds of sufferers who found relief through alternative medicine for the past 40 years it is very clear to me why the medical "industry" insists on their barbaric modalities.
It’s about the money, honey.
There's a reason people find "relief" in alternative medicine, and it ain't because of the medicine. Peddling "alternative medicine" is just as abhorrent and morally bankrupt as denying someone coverage because of a pre-existing condition or because they've suddenly become expensive to ensure.
Big Pharma and the medical industry at large may be lead by bloodthirsty thieves, but they can't get away with quackery.
Like a potion for restless leg syndrome?
Corruption favors the wealthy.
Who said anything about a potion?
"Big Pharma and the medical industry at large may be lead by bloodthirsty thieves, but they can't get away with quackery."
I think another whoa whoa whoa is in order here.
The medical industry and PhRma invented quackery. Fake drug trials, fake patient studies, fake research are all just another day at the office in the medical field, and this isn't even including the common frauds of Medicare billing, waste disposal and medical equipment frauds that are done solely for financial gain.Sure, they get caught more often by their peers, but that doesn't mean it doesn't happen.
But they have to feign their results, and those results are open to critical examination. They may get away with it temporarily, but as soon as someone tries to duplicate your results, you're screwed. That's the beauty of science, it's driven by the failure to disprove.
Alternative medicine that demonstrates results when exposed to the merciless scrutiny of the scientific community gets promoted to medicine. There's a reason physicists don't take Deepak Chopra seriously.
...of a shark won't inhibit cancer? :)
PS. Susie, I know that last step can be painful. Remember to exit the cab the same way you entered it and look out for the rocks and pebbles... they will mess you up! Hope things turn out fairly for you. Seems like the Ins. companies always got a leg-up on ya? ;) They just don't want to foot the bill... I talked to a podiatrist one time for hours... so long, that my foot fell asleep :) Alright I'm done now... ya don't have to kick me out!
Study the symptoms not the virus...
there's plenty of medicines/procedures that have not met gold standards to prove their effectiveness.
never fully underestimate the power of the placebo effect with some patients. many conditions and the personal variables of an individual can't be fully accounted for in regards to some conditions. no doubt "alternative medicine" needs more research. there's quackery in medicine also. there's also plenty of cheating. there have been procedures/medicines that reveal little to no use from placebos. like many alternatives.
http://www.nytimes.com/2009/08/05/health/rese...
But where did the first indication that something was wrong come from? Research.
From the NYT article...
"But the seeming consensus fell apart in 2002 when a huge federal study on hormone therapy was stopped after researchers found that menopausal women who took certain hormones had an increased risk of invasive breast cancer, heart disease and stroke. A later study found that hormones increased the risk of dementia in older patients."
The problem of industry influence hasn't been eradicated, but how many alternative medicine practices have been corrected in the face of data that contradicts their assertions?
no your right all medicine/medical procedures are proven effective/beneficial with proof of mechanism. i was alittle confused in the conversation. i was under the notion that not all procedures/medications were proven.sorry about that. getting my information wrong.
This is from a more recent (2007) BMJ Survey: Of around 2500 (medical) treatments reviewed, 13% were rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, as unknown effectiveness (see figure 1).
"So what can Clinical Evidence tell us about the state of our current knowledge? What proportion of commonly used treatments are supported by good evidence, what proportion should not be used or used only with caution, and how big are the gaps in our knowledge? Of around 2500 treatments covered 13% are rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, as unknown effectiveness (see figure 1). Dividing treatments into categories is never easy hence our reliance on our large team of experienced information specialists, editors, peer reviewers and expert authors. Categorisation always involves a degree of subjective judgement and is sometimes controversial. We do it because users tell us it is helpful, but judged by its own rules the categorisation is certainly of unknown effectiveness and may well have trade offs between benefits and harms. However, the figures above suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients."
i'm going to agree to disagree. research in my opinion is not absolute not suggesting you said that. i still say there are many procedures/medications that fall short in meeting gold standard proof of effectiveness. evidence based medicine will come up short at times regardless of the perceived research(medscape). research has often been found to be manipulated/leaned toward a persuasion.i was recently reading about a procedure vertebroblasty no better than placebo. my point is research is not absolute just like alternative treatments. like medical procedures consumers/patients need to make individual judgements regarding alternative treatments. to me that's part of the art and science of medicine.
http://clinicalevidence.bmj.com/ceweb/about/k...
(and no comments from the peanut gallery either!)
Here's what seems to be a foolproof way to deal with these schmucks.
http://community.nytimes.com/comments/www.nyt...
That is a good one. Thank you!
statusquObama, change you can only pretend in
Two things:
1. That really is a great post -- I'll forward it to friends. Thanks!
2. So, Alice, what do those little pyramids mean?
I am so glad you asked!
statusquObama, change you can only pretend in
I do, from time to time, manage to post something of merit without cussin.
};)>
Wed, 08/12/2009 - 12:51 — liberalNmoderation
(and no comments from the peanut gallery either!)
____________________________________________________________________
http://www.youtube.com/watch?v=NOe_4mgmyyA
http://www.youtube.com/watch?v=XSAkm3_kI84
Diabolus est Deus Inversus
that Bush didn't give your surgeon the Presidential Medal of failing upwards.
When a surgeon, when weighing the pros and cons of performing an invasive procedure, decides that his primary primary concern is whether the claim is an "easy" one, ought to do us all a favor and make their next decision to stop performing surgery and become a hospital administrator instead (or work for the insurance agencies deciding who to withhold care from since he's become familiar with the process already).
THIS is why we NEED universal coverage - extending the current system to more people just means more of the same ol' BS.
One of the things I used to like about having Kaiser HMO as my coverage was that the doctors i was dealing with (and I had extensive treatment there) seemed to be concerned almost exclusively with treatment rather than payment. This is not to say that I never had to deal with paper pushers that wanted to kick me out of the hospital, and my carrier actually dropped me as I was being wheeled in for surgery, but the DOCTORS? They never, ever, gave the appearance of valuing cost over health.
Maybe, at some point in my lifetime, health care in this country will start being about health rather than profit. (A girl can dream, can't she?)
Wolf Blitzer just opened a show with this "Death Panels" "How do we know what's true and what isn't?"
Wolf Blitzer want's to know if the Death Panels are true. Details are just moments away!
Wolf Blitzer will listen to a barrage of talking points from republicanz and then look blankly at the screen as CNN fades to commercial. and what of the news. what of the news.
"Government by organized money is just as dangerous as Government by organized mob"
-= Franklin Delano Roosevelt =-
I've been surprised that I haven't seen the happy smiling faces of the trial lawyers in this debate. One would think they would have a vested interest in fighting universal health care. Of course, they'll still have pain and suffering (up to the capped amounts), diminution of earnings and the other ancillary stuff. My guess, though, is that when we see the final bill, we'll find a little goody tucked away in it for the lawyers. It might even be something completely unrelated, but they'll get something out of it.
There are other things that would probably be unnecessary if universal health care were adopted -- workers comp, special compensation programs for things like newborn brain injury, etc.
The whole "tort reform" argument is basically a red herring. For starters, to my knowledge the Federal Government won't have the power to do what is the role of the states in setting "caps".
to have to base a law practice on, so few do it. There are so many other worthy things to sue for, like toxic chemicals, poison food, inferior appliances, credit card company thievery, criminal law, divorces, landlord tenant cases, real estate, estates and trusts, and so on. Your cheap shot missed the mark for those who know the truth. If someone fucks you over, are you going to call Ghost Busters or a lawyer?
The repubs got their tort reform. The only way a kid just out of law school can pay back their enormous debt is to work for the government, be an insurance defense lawyer or defend wealthy criminals. There are virtually no more wealthy trial lawyers. A few, but not many. They have been largely shut down. The media and judicial blitz against them has worked. There are still a few holes in the system where a lawyer can take a real case and win, but then the insurance company begins negotiations to settle as they file their baseless appeal in order to delay paying the judgment. I've seen many injured and sick people suffer mercilessly as a result of these large insurance companies welching and can easily see why the John Grisham novels fly off the shelves. Justice is expensive in the land of the free. I would also add that our ACLU lawyer friends were our last line of defense in the bush-cheeeny crimewave.
Marginally off topic, but I'm listening to C-SPAN covering a CBC panel discussing the possible pandemic of swine flu and it's expected impact on the health care services, including hospitals.
Children and young adults are most at risk for swine flu. They're also a sizeable chunk of the uninsured.
I expect Tea Baggers won't care about the financial impact of this (or consider it God's Will), but this might yet be one of those events that underscores the reality of being uninsured.
You edited before I could criticize!
changed the typo "your adults" to "young adults"....Feel free to criticize...
I know ... that's what I was going to suggest, respectfully, that you correct. NOT criticize! Not me! I'M not obsessive about typos! I can take them or leave them! Really!
Out of curiosity, what's the stand of the ABA on medical reform,
Won't we have a lot of fat lawyers if they can't chase after ambulances?
Diabolus est Deus Inversus
http://www.youtube.com/watch?v=WCkOmcIl79s
http://www.youtube.com/watch?v=-_IGxXxsoE8
Diabolus est Deus Inversus
They have come out for the current (though vaguely defined) program.
That should tell you immediately that it is a bad deal for the commonweal.
When big insurance, big pharma and the AMA like your program, it is because their support has been payed for at the public expense.
statusquObama, change you can only pretend in
Lobby groups who represent only the (already) Fat Cats in their profession. Like AARP who mainly tries to sell insurance policies to seniors. They are all crap.
And if we have public option for medical insurance
Will there be a public option for medical malpractice insurance?
Diabolus est Deus Inversus
medicine without interference from the insurance companies, the malpractice problem would shrink to manageable proportions. Do you want to NOT hold doctors and hospitals responsible when they screw up?
Just saw a guy in a town hall who works for a company that has 39,000 employees. He says management can decide at any time to eliminate health insurance and put them all on the public plan. Well, so what?
If you have a dire emergency, you will be seen right away on the public plan and receive excellent care. If you don't have a dire emergency, you must get used to waiting your turn so that others sicker than you can be taken care of first.
If you arn't direly sick but you can't seem to learn the virtue of patience, then you can be seen by a private doctor and pay the going rate, which by the way, will be less than what you're paying for insurance.
But the best thing you can do is stop letting greedy doctors on the take from the Pharm industry talk you into taking vials and vials of pills if you arn't direly sick -- because those chemicals are making you sick.
What I described above is the way it works in Europe and this is the best plan for everyone.
pretty serious subject though, since today Planned Parenthood Northwest Region got busted for chronically overcharging Medicare. http://www.spokesmanreview.com
Having experience with PP Spokane, I disagree with this report as presented. Yes, patients DO receive their birth control pills from the receptionist on a monthly basis. So they don't get lost, sold, or stolen.
Yes, nurse practitioners DO monthly screenings, because many are in the lower strata of society and would not get blood pressure checks, etc., elsewhere. This is preventative medicine.
However, the article does draw attention to the fact that there ARE people out looking for wrongdoing and it is pathetic that what they find is a misinterpretation of the critical services provided by PP. Keep yer eyes open out there for some real nasty shenanigans.
The United States aspires to democracy, but no true democracy is attainable when the process is determined by economic power.
Doing the same for public services, like they do to ACORN...trying to make it look bad so they can control/privatize/profit
It's important to note that when you're talking about auto insurance coverage for injuries such as described in your post, the facts, as presented, are related to New Jersey coverage only.
Each state has different types of coverage and most states are not "no fault states" so PIP and Medical Payments are optional in those states and how they are applied is often different than in New Jersey.
Only New Jersey gives you a premium discount for health insurance and that discount only applies if you select your health insurance as Primary vs your PIP (on your auto insurance) being Primary.
Greg
Susie:
Great post. In fact, I have written about this before, and reference your post on my blog http://nwbullseye.blogspot.com/2009/08/more-p...
Keep up the good work.
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