Copyright held by The John Cooke Fraud Report. Reprint rights are granted with attribution to The John Cooke Fraud Report with a link to this website.
By D. J. Osborne
“Can you imagine making a year’s income in a month’s time? Would you like to know how to double your revenues with personal injury patients? Would you like to know how to increase your weekly income by $8,000 to $10,000? ” These are just some of the questions asked by national provider fraud organizations that recruit doctors with promises of wealth. It is an unfortunate reality that some doctors have greed in mind rather than patient care and that they 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 is self-limiting in nature and will usually heal with or without treatment; approximately 90 percent spontaneously resolve within 90 days. These are minor injuries that are subjectively identified from patient complaints, or what patients tell the doctor. Many of these injuries 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 soft tissue injury as the typical fraud related injury claim, reporting that unscrupulous medical and legal providers have the largest monetary incentives to participate in this fraud. The NICB reports that both the frequency and the cost of these claims are on the rise. An Insurance Research Council study reports soft tissue injuries were filed by 83 percent of claimants in at fault auto accidents in 1992, up 75 percent from five years earlier, and average claim costs are about four times higher than they were 15 years ago. The NICB estimates that the average American household pays an additional $200 each year in premiums as a result of the $20 billion annual insurance fraud problem!
This minor injury is a major problem for insurers and for consumers. This does not occur by accident but because of the specific intent and design of the national provider fraud organizations, which travel the country to find doctors willing to do whatever it takes to make more money. Large numbers, interested only in the riches advertised, are attracted and will do whatever it takes! Here, the soft tissue injury is the perfect medical condition for fraud, and the prescription is to use soft tissue injuries for blatant and costly fraud schemes, following a Recipe For Wealth! This recipe calls for specific ingredients:
1) Use any and all means, including professional associations and solicitation scams, to get people with insurance in the door.
2) Turn everyone with insurance into a patient, regardless of medical condition or need.
3) Keep patients coming back, regardless of need, until their medical coverage runs out or is cut off.
4) Bill insurers for comprehensive examinations not provided, worthless diagnostic tests and unnecessary treatment.
5) Use aggressive tactics, the legal system and political connections to make insurers pay.
This recipe is only about making money, not about 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 doctor who follows this recipe uses his profession, his position in society and our trust, to steal through costly exams, tests and treatments!
Ingredient #1 above is very troubling; not only for the financial impact it may cause, but for the public safety concern it creates for patients. This ingredient calls for doctors to seek out patients with insurance, with little or no regard for patient welfare, to be used as vehicles to steal. One of the more common tactics used to fulfill this ingredient is the advertisement of free exams, reportedly offered as a public service by doctors concerned about the public’s health because people may be injured but not know it!
These free exams, offered through advertisements, coupons, store screenings, free dinners, phone calls and/or letters, are no public service! It is a bait and switch scam, with the exam (bait) providing doctors with the opportunity to hard sell people with insurance on the need for treatment and to recruit them as patients (switch). The first thing examined is available insurance, identified from questionnaires. Actual injuries make little difference in the free exam scams; available insurance is the basis for treatment. Doctors using this tactic are rolling the dice and finding that 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? And just how is the doctor supposed to diagnose a soft tissue injury on someone who doesn’t know he is hurt? If someone is not hurt, will that person have the (subjective) complaints the doctor needs to diagnose this condition? Further, why would a doctor examine someone for free? Are doctors really so concerned about people’s health that they will provide free medical service? Not likely.
Favorite targets of these exams are auto accident victims identified from police reports. The police report not only documents the auto accident, it also provides contact and insurance information on the victim(s). Both medical and legal professionals see money in the form of future insurance claims, aggressively soliciting auto accident victims by mail and phone. Victims may be contacted by multiple sources following accidents, even businesses that are located in other parts of the country but solicit for local professionals.
Ingredient #4 of the above recipe is of particular interest and importance to fraud fighters. By including this ingredient, doctors engage in fraud that is provable beyond a reasonable doubt! They bill for services that are impossible to provide and for others that are absolutely worthless for diagnosing soft tissue injuries. When a claims professional knowledgeable about the meaning of billing codes holds the doctor accountable for the service billed, there is powerful evidence to stop these doctors.
Current Procedural Terminology Codes, commonly known as CPT Codes, are used by most medical providers even by doctors following the above recipe to obtain payment. The American Medical Association promulgated CPT Codes so that all medical providers could accurately report services and collect proper compensation. The codes are based on the amount of work done, judgment used and medical risks to the patient. The codebook instructs providers using the codes to “select the code(s) that most accurately identifies the service performed. “
An easy way to determine what services were billed is to use the CPT Codes to break the bills down by category of service: exams, tests or treatment. Calculate each category to find the respective totals billed. Typically, when the bills are broken down, less than half of the doctor’s bill is for treatment(services to assist patients in getting to a better state of health). The majority of the bill is for exams and tests. Additionally, patterns can be identified wherein identical services are billed on all patients.
Further, if we know what treatment is required under the CPT code for the services billed by those doctors following the above recipe for fraud, evidence can be established to stop these costly schemes. These doctors do not select codes that most accurately identify the services provided. The comprehensive exams usually billed are impossible to perform on patients with soft tissue injury. Many of the tests billed claim to provide objective data, which is impossible for a subjective injury. 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 codes include five levels of exam 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 examination: 1) history, 2) physical exam and 3) medical decisions. Each component will have varying requirements, depending on the level of exam service reported, that must be met or exceeded to bill for these exam services. The more serious the problems and risks to the patient, 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. The CPT codebook reports doctors typically take 60 minutes of face-to-face time with patients and/or family, to complete comprehensive exam. During such exams 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 by definition and is conducted only 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 a comprehensive examination. The medical risks of their soft tissue patients are far less than the risks inherent to patients who require 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 doesn’t pay as well! These highly educated and trained medical professionals knowingly avoid the proper exam code and purposely bill for a service not provided in order 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 claim to provide objective data on the subjective soft tissue injury. Is this possible? Can one gain objective data on subjective injuries? Wouldn’t this make the injuries objective? Even if this were possible, what difference would objective data have for an injury that will heal in time with or without treatment? The difference is the increase in the patient’s bill achieved by including charges for worthless tests. Typically, these tests take less than 10 minutes, are performed on a specific body area by an unlicensed assistant and cost more than double what the doctor charged for the whole body examination.
CPT codes do not include a specific code for many of the tests billed by those doctors who are following the recipe. However, the national provider fraud organizations will instruct the doctors on what codes to use to misrepresent the service provided. Most of these stated objective tests are not recognized either clinically or scientifically, and they do not provide the objective data claimed. For the most part, these tests are taught not at accredited schools but in weekend seminars, presented by those with a vested financial interest in the specific test. This lack of validity hasn’t stopped these doctors.
One would think that for all the comprehensive exams reported and billed, these doctors would have all the information needed to treat a condition identified from what patients tell them. But the tests have little or nothing to do with making the patients better; they are simply ingredients for increasing wealth. The national fraud provider 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 that 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 that a doctor only supervise the treatment and assure that the correct treatment was provided, that it was administered properly and tithe right body area and that it was administered for the appropriate time. The treatment must have some relationship to the reported injury; as such, treatment available for soft tissue injuries is limited, but specific requirements must be met prior to billing for treatment service.
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 each patient in and out in less than 10 minutes. With all the free exams, comprehensive exams and tests that are reported, where do these doctors find the time to treat all these patients? Maybe this is another reason these national organizations 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 who want the riches advertised, who will knowingly and purposely engage in the costly and systematic fraud schemes advocated by the organizations to get it. They are criminals who just happen to be doctors! They have contempt for society; they abuse their status and our trust in order 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, they 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,” a quote brought to my attention some years back by a medical professional committed to stopping this criminal activity, is appropriate here. If one knows what the criminals, who happen to be doctors, are doing, one can see how to stop them!
D. J. Osborne is a special agent with the NICB specializing in provider fraud. He can be reached at (800) 323-8650.
© Copyright 1997 Alikim Media