August 12, 2009


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.

Can you help us out?

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