Insurance Company Scams
With escalating medical costs the insurance companies in an attempt to remain solvent and responding to new insurance laws throughout the United States are now proceeding with a new scheme to defraud both consumers and state insurance commissions.
This scheme serves a dual function:
1) it inflates the insurance
companies potential liabilities
2) it creates the impression of provider misconduct by targeting high
profile doctors.
The physicians who have the highest dollar billing in each insurance category and company are accused of the same kind of fraud that the government attacked insurance companies for in the past years. What is the motivation for these types of attacks? Of course, cost containment is the most obvious.
However, using non-medical examiners to evaluate and validate medical claims reduces insurance costs. Further by creating duplicate billing through the insurance company computer systems, insurance companies can now make it appear as if providers were defrauding the insurance company. An additional benefit for these companies is that this procedure allows the insurance company to report a continuing increased loss in income to the state insurance commissioners. Thereby, getting their requests for state insurance waivers looked upon in a more favorable light.
The state insurance commissioner does not want the insurance company to go out of business. The threat that the insurance company will default is enough to get insurance waivers not normally available. A further danger to the insurance companies is their inability to meet their monthly 2% cash escrow accounts required by law. This occurs by failing to correct their computer system errors and acting as though they were unaware that such errors exist.
Creating doubt about provider billing practices allows the insurance company to reject all claims from that provider thereby reducing their monthly liabilities and outstanding monthly claims. In the instance of the State of New York's Prompt Payment Law recently enacted further increases insurance executives decision-making processes. Changes in New York State Insurance Policies make it more difficult to question client submissions so doctors as providers become the targets of cost-containment.
Claims Submitted by Providers must follow the insurance companies policies and procedures or the physician billing an insurance company will have their claims rejected. If the Provider is not part of that particular insurance companies program, how do they obtain the correct billing information.
In a recent hands-on-investigation, the Rational Observer- observed as a coder attempted to obtain this information from insurance companies. The insurance companies refused to supply providers with the correct billing codes to be reimbursed. This allows the insurance companies to then CRY FRAUD to the state insurance commissioner's office. As Health Care Reform comes to the forefront in this year's Presidential Elections...the question is WHO IS MAKING SURE OUR REPRESENTATIVES DO WHAT IS BEST FOR ALL THE PEOPLE !!
In the end most private doctors can no longer afford to meet their daily practice expenses based upon the amount allowed by insurance carriers. Doctors billing for questionable practices from the insurance companies point of view suddenly find themselves deluged by computer errors. The source of which is the insurance company; not the doctor and which the insurance company uses to question, defer and/or refuse payment. Claims Submitted by Insurees go through a similar process discredit, confuse, and refuse payment to insurance company subscribers. Only insurees who submit reimbursement claims by return receipt /certified mail can be assured of relatively rapid payment. Claims examined by an Error Analysis of Claims processed by Blue Cross/Blue Shield of Massachusetts and Empire Blue Cross/Blue Shield of New York showed the insurance company had generated three different submissions on two different claim numbers for the same date of service.
This error allows the insurance company to question the providers billing practices when the root of the problem is in the insurance companies computer systems. All large insurance companies are aware of major computer systems errors in their claims processing systems. For the FBI to claim that it had examined all claims from any one provider and had not identified any prevalence of errors makes all claims from this source invalid. The recent questioning of the efficacy of healthcare claims examination by United Health Care threatens a large mid-level bureaucracy whose usefulness now seems at an end and whose jobs will be eliminated. The FBI functionaries who examine billing practices are under pressure to show their usefulness. Their assertion of errorless claim processing only demonstrates their ignorance.
The FBI agents working with doctors supplied by the insurance companies draw conclusions about the frequency and quality of the procedures performed by doctors. Among the complaints are that multiple procedures are performed at any one intervention. The FBI fails to note that it is a doctor's affirmative obligation to take care of all and any problems that can be resolved during any one surgical procedure.
The FBI failed in his duties due to the fact that they failed to perform any quality control of the insurance companies computer systems or conduct any error analysis in any insurance companies claims processing procedure analysis. This failure calls into question the reliability of the information into our cases brought to our courts.
Insurance companies are required to maintain computer tape backups of all insurance claims. A subpoena for all the computer tapes for all the insurance companies involved at the expense of the insurance company will provide definitive identification of the number of Errors in duplicate billing practices on behalf of the fraud claims generated by local, state or federal governments in conjunction with the insurance companies.
To find out what our government knows about this medical billing errors, read the
Exclusive to the Rational Obeserver by F. Straus
