Many frauds can be detected by examining insurance payment reports to
see whether they accurately reflect the services rendered
--------------------------------
Insurance Fraud and Abuse:
A Very Serious Problem
Stephen Barrett, M.D.

Fraud and abuse are widespread and very costly to America's health-
care system. Fraud involves intentional deception or
misrepresentation
intended to result in an unauthorized benefit. An example would be
billing for services that are not rendered. Abuse involves charging
for services that are not medically necessary, do not conform to
professionally recognized standards, or are unfairly priced. An
example would be performing a laboratory test on large numbers of
patients when only a few should have it. Abuse may be similar to
fraud
except that it is not possible to establish that the abusive acts
were
done with an intent to deceive the insurer.

Although no precise dollar amount can be determined, some authorities
contend that insurance fraud constitutes a $100-billion-a-year
problem. The United States Goverment Accountability Office (GAO)
estimates that $1 out of every $7 spent on Medicare is lost to fraud
and abuse and that in 1998 alone, Medicare lost nearly $12 billion to
fraudulent or unnecessary claims [1].

Type of Fraud and Abuse
False claim schemes are the most common type of health insurance
fraud. The goal in these schemes is to obtain undeserved payment for
a claim or series of claims [2]. Such schemes include any of the
following when done deliberately for financial gain:

Billing for services, procedures, and/or supplies that were not
provided.
Misrepresentation of what was provided; when it was provided; the
condition or diagnosis; the charges involved; and/or the identity of
the provider recipient.
Providing unnecessary services or ordering unnecessary tests [3].
Many insurance policies cover a percentage of the physician's "usual"
fee. Some physicians charge insured patients more than uninsured ones
but represent to the insurance companies that the higher fee is the
usual one. This practice is illegal. It is also illegal to routinely
excuse patients from copayments and deductibles. (A copayment is a
fixed dollar amount paid whenever an insured person receives
specified health-care services. A deductible is the amount that must
be paid before the insurance company starts paying.) It is legal to
waive a
fee for people with a genuine financial hardship, but it is not legal
to provide completely free care or discounts to all patients or to
collect only from those who have insurance. Studies have shown that
if patients are required to pay for even a small portion of their
care they will be better consumers and select items or services
because
they are medically needed rather than because they are free. Routine
waivers thus raise overall health costs. They are considered
fraudulent because averaging them with the doctor's full fees would
make the "usual" fees lower than the amounts actually billed for.

Other illegal procedures include:

Charging for a service that was not performed.
Unbundling of claims: Billing separately for procedures that normally
are covered by a single fee. An example would be a podiatrist who
operates on three toes and submits claims for three separate
operations.
Double billing: Charging more than once for the same service.
Upcoding: Charging for a more complex service than was performed.
This
usually involves billing for longer or more complex office visits
(for
example, charging for a comprehensive visit when the patient was seen
only briefly), but it also can involve charging for a more complex
procedure than was performed or for more expensive equipment than was
delivered. Medicare documentation guidelines describe what the
various
levels of service should involve [4].
Miscoding: Using a code number that does not apply to the procedure.
Kickbacks: Receiving payment or other benefit for making a referral.
Indirect kickbacks can involve overpayment for something of value.
For example, a supplier whose business depends on physician referrals
may
pay excessive rent to physicians who own the premises and refer
patients. Another example would be a mobile testing service that
performs diagnostic tests in a doctor's office. Kickbacks can distort
medical decision-making, cause overutilization, increase costs, and
result in unfair competition by freezing out competitors who are
unwilling to pay kickbacks. They can also adversely affect the
quality of patient care by encouraging physicians to order services
or
recommend supplies based on profit rather than the patients' best
medical interests. In 2000, the Office of the Inspector General
issued a fraud alert warning against kickbacks disguised as rental
payments
[5].
Criminals sometimes obtain Medicare numbers for fraudulent billing by
conducting a health survey, offering a free "health screening" test,
paying beneficiaries for their number, obtaining beneficiary lists
from nursing homes or boarding facilities, or offering "free"
services, food, or supplies to beneficiaries.

Excessive or Inappropriate Testing
Many standard tests can be useful in some situations but not in
others. The key question in judging whether a diagnostic test is
necessary is whether the results will influence the management of the
patient. Billing for inappropriate tests—both standard and
nonstandard
—
appears to be much more common among chiropractors and joint
chiropractic/medical practices than among other health-care
providers.
The commonly abused tests include:

Computerized inclinometry: Inclinometry is a procedure that measures
joint flexibility. Inclinometer testing may be useful if precise
range- of-motion measurements are needed for a disability evaluation,
but
routine or repeated measurements "to gauge a patient's progress" are
not appropriate [6].
Nerve conduction studies: These tests can provide valuable
information about the status of nerve function in various degenerative
diseases
and in some cases of injury [7]. However, "personal injury mills"
often use them inappropriately "to "follow the progress" of their
patients. Surface electromyography: This test, which measures the
electrical
activity of muscles, can be useful for analyzing certain types of
performance in the workplace. However, some chiropractors claim that
the test enables them to screen patients for "subluxations" and to
follow their progress. This usage is invalid [6].
Thermography: Thermographic devices portray small temperature
differences between sides of the body as images. Chiropractors who
use thermography typically claim that it can detect nerve impingements
or
"nerve irritation" and is useful for monitoring the effect of
chiropractic adjustments on subluxations. These uses are not
appropriate [6].
Ultrasound screening: Diagnostic ultrasound procedures have many
legitimate uses. However, ultrasonography is not appropriate for
"diagnosing muscle spasm or inflammation" or for following the
progress of patients treated for back pain [6].
Unnecessary x-rays: X-rays examinations can be important to look for
conditions that require medical referral. However, it is not
appropriate for chiropractors to routinely x-ray every patient to
look for "subluxations" or to "measure the progress" of patients who
undergo spinal manipulation [6].
Spinal videofluoroscopy: This procedure produces and records x-ray
pictures of the spinal joints that show the extent to which joint
motion is restricted. For practical purposes, however, simply
physical examination procedures (such as asking the patient to bend)
provide
enough information to guide the patient's treatment [6].
Many insurance administrators are concerned about chiropractic claims
for "maintenance care" (periodic examination and "spinal adjustment"
of symptom-free patients) , which is not a covered service. To detect
such care, many companies automatically review claims for more than
12
visits. In 1999, the U.S. Inspector General recommended automatic
review after no more than 12 visits for Medicare recipients [8]. Some
chiropractors attempt to avoid review by issuing a new diagnosis
after the 12th visit.

Personal Injury Mills
Many instances have been discovered in which corrupt attorneys and
health-care providers (usually chiropractors or chiropractic/medical
clinics) combine to bill insurance companies for nonexistent or minor
injuries. The typical scam includes "cappers" or "runners" who are
paid to recruit legitimate or fake auto accident victims or worker's
compensation claimants. Victims are commonly told they need multiple
visits. The providers fabricate diagnoses and reports and commonly
provide expensive but unnecessary services. The lawyers then initiate
negotiations on settlements based upon these fraudulent or
exaggerated medical claims. The claimants may be unwitting victims or
knowing
participants who receive payment for their involvement [9]. Mill
activity can be suspected when claims are submitted for many
unrelated individuals who receive similar treatment from a small
number of
providers.

Quackery-Related Miscoding
In processing claims, insurance companies rely mainly on diagnostic
and procedural codes recorded on the claim forms. Their computers are
programmed to detect services that are not covered. Most insurance
policies exclude nonstandard or experimental methods. To help boost
their income, many nonstandard practitioners misrepresent what they
do. They may also misrepresent their diagnosis. For example:

Brief or intermediate-length visits may be coded as lengthy or
comprehensive visits.
Patients receiving chelation therapy may be falsely diagnosed as
suffering from lead poisoning; and the chelation may be billed as
"infusion therapy" or simply an office visit [10].
The administration of quack cancer remedies may ...

read more »

read more »

What the Democratic bill does not do is add another layer of laws
against fraud.  US law books are littered with laws against fraud,
theft, embezzlement, and every other dishonest act one can think of.
There is no need for more laws outlawing fraud. But Republicans insist
that the healthcare bill must include something about fraud, perhaps
another statement that fraud is a punishable crime, or some such
superfluous statement of policy, or the Republicans will oppose the
bill.

In other words, the Republicans want some federal power to act as
protector of the insurance companies against fraudulent claims.
Protecting the insurance companies is at the top of the Repubican
agenda.  It's all just the same corrupt politics the Republicans have
become known for.

Where, when, how?

Or are you WASTING EVERYONE'S TIME LYING like you always do:

Oops!  YOU have been CAUGHT LYING, again...

On Thu, 27 Aug 2009 05:14:42 -0700 (PDT), snakehawk

It's A Good Time To Work For Uncle Sam
May 12, 2009

At a time when the official unemployment rate is nearing double
digits, and 6.35 million people are receiving unemployment benefits,
the U.S. government is on a hiring binge.

Executive branch employment — 1.98 million in 2009, excluding the
Postal Service and the Defense Department — is set to increase by 15.6
percent for the 2010 fiscal year. Most of that is thanks to the Census
Bureau hiring 102,000 temporary workers, but not counting them still
yields a net increase of 2 percent in one year.

There's little belt-tightening in evidence in Washington, D.C.:
Counting benefits, the average pay per federal worker will leap from
$72,800 in 2008 to $75,419 next year.

Meanwhile, according to Forbes' layoff tracker, there have been
558,087 layoffs since November 2008 at large public companies; even
local school districts aren't immune. That's just a sliver of the
total unemployed, which government data estimate to be 8.6 percent of
the workforce, or an alternate method of reckoning that counts
discouraged workers puts at 20 percent.

Some of the Feds' hiring increases have been stunning. If you look at
the four-year period from 2006 to 2010, the number of Homeland
Security employees has grown by 22 percent, the Justice Department has
increased by 15 percent, and the Nuclear Regulatory Commission can
claim 25 percent more employees. (These figures assume that Congress
adopts Mr. Obama's 2010 budget without significant changes.)

A 39-page "dimensions" document accompanying the White House's
1,380-page appendix offers justifications for each new hire. Homeland
Security says its new employees will "increase border security." The
Agency for International Development wants to improve "the management
and stewardship of foreign assistance programs." The Smithsonian
Institution wants "additional security guards." And so on.

The final evidence that it's a good time to have a .gov e-mail
address? Civilian government employees are set to enjoy a 2 percent
raise. Not only are private sector workers are struggling to keep
their jobs, but their earnings are stagnating and pay cuts are no
longer uncommon.
http://www.cbsnews.com/blogs/2009/05/12/business/econwatch/entry50078...

-------------------------------

Stimulus Package to Increase Government Hiring
April 20, 2009

The federal government will need to hire an additional 200,000 workers
over the next three years as a result of President Obama's stimulus
plan and additional spending included in his budget plan.

That may sound like a lot of jobs, but it's just slightly less than
half of the 384,000 additional employees Uncle Sam already needed to
pick up between 2009 and 2012 just to replace existing federal
employees expected to leave their jobs. "That 384,000 is a projection
for retirements, voluntary separations, reductions in force and a few
folks who will die on the job," says John Palguta, vice president of
policy for the Partnership for Public Service, a Washington, DC,
advocacy group working to advance public-sector careers.

With a total of nearly 600,000 openings over the next three years,
what options could there be for you?

About 85 percent of federal jobs are located outside Washington, DC.
But, since many stimulus-related jobs involve command, control,
tracking or oversight, a sizable proportion -- up to 22 percent --
could be located in the District of Columbia itself, Palguta says.

Who's Hiring?

The federal government currently employs 1.9 million civilians --
about the same number it did during the Kennedy administration. Gerald
Ford, Jimmy Carter, George H.W. Bush and Bill Clinton downsized the
federal bureaucracy, while Ronald Reagan and George W. Bush increased
it, Palguta says.

Some of this administration's 200,000 extra workers will be added
thanks to changing priorities. For example, President Obama's 2010
budget increases funding for the Social Security Administration (SSA),
so it can hire additional employees to work through a backlog of
cases. The agency will hire more than 5,000 people by September 2009,
says Kia S. Green, an SSA spokesperson. "These include front-line
positions in the local field offices and Teleservice Centers as well
as legal support positions in our hearing offices," she says.

Another budget priority -- better care for veterans -- resulted in a
$25 billion increase for the Department of Veterans Affairs. "A good
part of that will go into hiring more medical and health professionals
in the VA," Palguta says.

Jacque Simon, public policy director for the American Federation of
Government Employees, says agencies expected to add staff due directly
to the stimulus include the Environmental Protection Agency; the
Department of Defense; the Food and Drug Administration; the Border
Patrol; the Small Business Administration; the departments of Labor,
Education, Agriculture and Housing and Urban Development; and the
National Science Foundation.

Many agencies are still toting up the numbers. The Environmental
Protection Agency estimates it will take tens of thousands of
contractors and employees to handle clean up, assessments, design and
monitoring of the projects in the areas it will target with stimulus
money. These areas include Superfund sites, brownfields, leaking
underground storage tanks, clean water, drinking water and reducing
diesel emissions.

Bring on the Watchdogs

With so much stimulus money flowing out of Washington, DC, virtually
every agency will have to hire additional auditors, attorneys and
investigators to handle the fraud that will inevitably follow. In
government, those positions are part of the Inspector General's office
within each agency or department.

"The Inspectors General are going to be beefing up staff," Palguta
says. The Department of Health & Human Services www.hhs.gov, for
example, has $27 million for increased oversight. In addition,
Congress slotted $50 million to create the Recovery Act Transparency
and Accountability Board, a group of Inspectors General that will
watch over stimulus spending.

Given the talk about tighter regulatory scrutiny of the financial
markets, there will also likely be jobs openings at the Treasury
Department and the Securities and Exchange Commission.

The Government Accountability Office planned to start hiring 100
people familiar with government auditing by mid-March 2009, says
Patrina Clark, deputy chief human capital officer.

Prior federal government auditing experience is great, but it's not
the only way to qualify for these positions. "If they've done any kind
of state or government auditing, or they've audited public entities or
nonprofits, that would be qualifying experience," Clark says.

Focus on the Mission

If a federal job is your best career move, don't look for a stimulus
job -- look for a government job, Palguta says. "Look at who's got a
job to fill and which agencies have a mission that you're interested
in," he suggests. Gather career information by visiting the official
federal government hiring site as well as the individual agency Web
sites.

Expect to have a lot of company when you apply. In January 2009, after
the Federal Bureau of Investigation said it wanted to hire 2,100
professional staffers, it received 230,000 applications. "There are a
lot of people vying for those jobs," an FBI spokesperson says.

As long as you're not working in retail, chances are the federal
government hires people from your profession, Simon says. For example,
a VA hospital hires everyone from food-service workers right up to
brain surgeons. Even at an advanced career level, professionals from
information technology, legal, law enforcement, healthcare, science,
engineering, program management, purchasing and education are all in
demand.

And, working for the federal government often means swapping a
bottom-line focus for a public-interest one. "You're concerned with
what's in the best interest of your fellow citizens and how to best
serve them," she says.
http://www.enctoday.com/news/government-1169-syndication-hiring-incre...

Tater

* Bills from just one hospital stay will come from many providers:
doctors, anesthesiologist, pathologist, labs, as well as the
hospital.  It's impossible to determine everyone who did something for
you.

* Doctors will bill you even if they weren't significantly involved in
your case.  If they looked at your chart for a minute you could get a
"consultation fee" of $300.  You can get bills from some doctors who
were not involved at all.

* Hospital bills use medical jargon and code words that even experts
can't understand.  Hospitals are using their system of hiding their
prices through incomprehensible bills.

* Items on the bill will be so general it's impossible to figure out
what they refer to.

* Charges will be added for things that were never done. Nora Johnson
found when her 56-year-old husband, Bill, underwent hip-replacement
surgery in 1999. The cost of the operation was $25,000. When she asked
for and got an itemized bill, it included things "Like the charge for
newborn blood tests and a crib mobile. That stopped me in my tracks,"
recalls Johnson. "As far as I know, my husband never had a baby."
http://moneycentral.msn.com/content/Insurance/Insureyourhealth/P74840...

* Inflating charges for common items.  "I've seen $90 charged for a 70-
cent I.V. How about $129 for a mucous recovery system? That's a box of
Kleenex," Johnson adds. She's also seen charges for ordinary supplies,
such as towels and sheets, that should be included in the room
charges.  How about $5.50 for "analgesic medication"; that turned out
to be 2 Tylenol.

* Changing the code used on a bill to one for a diagnosis that has a
higher price.

Note that these are not isolated incidents or accidents.  Studies by
independent auditors, consumer reports, and other groups have found
that it has become routine for hospitals and doctors to inflate their
bills.

"A new study designed to uncover the key to understanding hospital
prices confirms what large purchasers have long suspected: a
disturbing number of hospitals appear to be grossly overcharging and
not being held accountable.

If you've ever spent time in a hospital, you've almost certainly been
overcharged. "There is no way to avoid being overbilled. It is going
to happen. In the last several years of looking at hundreds of bills,
I've run across only one hospital bill with no errors," says Edward
Waxman of Edward R. Waxman & Associates, an independent hospital bill
auditor with 10 years of experience helping consumers sort through
their medical bills."

http://moneycentral.msn.com/content/Insurance/Insureyourhealth/P74840...
http://www.health.com/health/money-article/0,,20221597,00.html
http://www.bankrate.com/brm/news/insurance/20040206a1.asp
http://www.consumerreports.org/cro/money/personal-investing/check-med...
http://www.cnn.com/video/#/video/health/2010/03/01/cohen.health.care....
http://www.hsacoalition.org/2008/01/18/two-simple-steps-to-immediatel...
http://www.consumersunion.org/health/unisuredfctwc.htm
http://www.businessreporter.org/hospitals-overchage-uninsured-patient...