The article below is from a 1997 article, however, many of the recipe items are still being used – one of the big differences today is that providers following the recipe are more careful on the reporting of comprehensive exams but the billing for physical medicine & rehabilitation services – especially, therapeutic procedures, has been inserted.
Can you imagine making a years income in a month’s time? Would you like to know how to increase your weekly income $8,000 to $10,000? These are just some of the questions asked by national provider fraud organizations who recruit doctors with promises of wealth.
It is an unfortunate reality that some doctors have greed in mind, not patient care, and 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 are self-limiting in nature and will heal with or without treatment, where 90% are spontaneously resolved in 90 days. These are minor injuries that are subjectively identified from patient complaints, or what patients tell the doctor, and, for the most part, 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 the soft tissue injury as the typical fraud-related injury claim. And, reports that unscrupulous medical and legal providers have the largest monetary incentives to participate in this fraud. The NICB reports the frequency and costs of these claims are on the rise, revealing an Insurance Research Council study that reports soft tissue injuries were filed by 83% of claimants in at-fault auto accidents in 1992, up 75% from five years earlier, and claim costs are about four times higher, on average, than 15 years ago. The NICB estimates that the average American household pays an additional $200 each year in premiums to pay for the $20 BILLION annual insurance fraud problem!
This minor injury is a major problem for insurers and consumers – not by accident – but by the specific intent and design of the national provider fraud organizations, who travel the country to find doctors willing to do whatever it takes to make more money. Large numbers are attracted that want the riches advertised, and will do just that – whatever it takes! Here, the soft tissue injury is the perfect medical condition for fraud, as the prescription is to use soft tissue injuries, in blatant and costly fraud schemes, and follow a RECIPE FOR WEALTH! This recipe calls for specific ingredients:
Use any and all means, to include professional associations and solicitation scams, to get people with insurance in the door.
Turn everyone with insurance, regardless of medical condition or need, into patients.
Keep patients coming back, regardless of need, until the insurance runs-out, or is cut-off.
Bill insurers for comprehensive exams not provided, worthless diagnostic tests and unnecessary treatment.
Use aggressive tactics, the legal system and political connections to make insurers pay.
This recipe is only about making money, not 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 doctors following this recipe use their profession, position in society and out trust, to steal through costly exams, tests and treatments! Evident by looking at the ingredients above, especially numbers one and four.
Ingredient one is very troubling, not only for the financial impact it may cause, but more importantly for the public safety concern it creates for patients. This ingredient calls for doctors to seek out people with insurance, giving little or no regard to patient welfare, to be used as vehicles to steal. One of the more common tactics used to fulfill this ingredient are “FREE EXAMS”, reportedly offered, as a public service by doctors concerned about our health-because we may be injured and not know it!
The “FREE EXAMS”, offered through advertisements, coupons, store screenings, free dinners, phone calls and/or letters, are not public service! The “FREE EXAM” is a bait and switch scam; with the exam (BAIT) providing doctors the opportunity to hard sell people with insurance on the need for treatment and to become patients (SWITCH). The first thing “examined” is available insurance, identified from questionnaires, where actual injuries make little difference in the “FREE EXAM” scams, but available insurance is the basis for treatment. Doctors using this tactic are rolling the dice to find: 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? I know when I am hurt, don’t you? How do doctors diagnose soft tissue injuries on people who don’t know they are hurt? If you are not hurt, will you have the (subjective) complaints the doctor needs to diagnose this condition? Further, why would a doctor examine us for free? Are the doctors really so concerned about our health that they will provide us with a free medical service? I don’t think so, do you?
Favorite targets of these EXAMS are auto accident victims identified from police reports. The police report not only documents the auto accident, but also provides contact and insurance information on the victim (s). Both medical and legal professionals see money in the form of future insurance claims, and aggressively solicit auto accident victims by mail and phone. Victims may be contacted by multiple sources following accidents, even businesses located in other parts of the country who solicit for local professionals.
The fourth ingredient of the recipe is of particular interest and importance to fraud fighters, whereby completing this ingredient, doctors engage in provable, beyond a reasonable doubt, fraud! They bill for services impossible to provide, and for others that are absolutely worthless when diagnosing soft tissue injuries. If held accountable for the services billed, and, by knowing what the billing codes mean, we have powerful evidence to stop these doctors.
CURRENT PROCEDURAL TERMINOLOGY or CPT Codes are used by most medical providers, even doctors following the recipe, to get paid. The American Medical Association promulgated CPT Codes so that all providers could accurately report services and collect proper compensation. These codes are based on the amount of work done, judgment used and medical risks to patients, and instruct providers using the codes to select the code (s) that most accurately identifies the service (s) performed.
An easy way to determine what services were billed is to use the CPT Codes, and break the bills down by category of services: EXAMS-TESTS-TREATMENT. Calculate each category to find the respective totals billed. Typically, by breaking the bills down, we find that less than half of the doctor’s bill is for treatment (services to assist patient’s in getting to a better state of health), and the majority of the bill is for exams and tests. Additionally, patterns are identified wherein the exact same services are billed on all patients.
Further, if we know what is required by CPT on the services billed by the doctors following the recipe, we can establish our evidence to stop their costly schemes. These doctors are not selecting codes that most accurately identify their services. Many of the exams billed are comprehensive, which are impossible to perform on patients with soft tissue injury. Many of the tests billed purport objective data, which is impossible on a subjective injury. And, 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 has five levels of exams, 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 exam: 1) History, 2) Physical Exam, and 3) Medical Decisions. Each component will have varying requirements, depending on the level service reported, that must be met, or exceeded, to bill exam services. 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. CPT reports it typically takes doctors 60 minutes, face to face with patients and/or family, to complete comprehensive exams, where 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 and is conducted 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 the comprehensive examinations. The medical risks of their soft tissue patients are far less than the risks inherent to patients that need 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 will not pay as well! Indicating, these highly educated and trained medical professionals knowingly avoid the proper exam code, and purposefully report a service not provided 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 purport objective data on the subjective soft tissue injury. Is this possible? Wouldn’t this make the injuries objective? Even if possible, what difference would objective data have on a injury found only after the patient identified it, that will heal in time, with, or without treatment? The difference is to increase the patient’s bill with charges for worthless tests. Typically, the tests, administered by an unlicensed assistant, in less than 10 minutes, on a specific body area, cost more than double what the doctor charged for their whole body examination.
CPT does not have specific codes for many of the tests billed by doctors following the recipe. However, the national provider fraud organizations will instruct what codes to use, to misrepresent the service provided. Most of these stated objective tests are not recognized clinically or scientifically, and do not provide the objective data claimed. For the most part, the tests are not even taught at accredited schools, but are taught in weekend seminars by those with a vested financial interest in the specific tests. This lack of validity hasn’t stopped these doctors.
Wouldn’t you think that in all the comprehensive exams reported and billed, that these doctors would have all the information needed to treat (a condition identified from what patients tell them)? The tests have little or nothing to do with making patients better, but are ingredients for wealth. The national provider fraud 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 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 only that a doctor supervise the treatment-the correct treatment was provided, administered properly, on the right body area, and for the appropriate time. The treatment must have some relationship to the reported injury, and as such, treatment available for soft tissue injuries is limited, but the specific requirements must be met prior to billing treatment services.
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 patients in and out in less than 10 minutes. With all the “FREE EXAMS”, comprehensive exams, and tests that are also reported, where do these doctors find the time to treat all these patients? Maybe, this is another reason the national organization 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, that want the riches advertised, who will knowingly and purposefully, engage in the costly and systematic fraud schemes advocated by the organizations, to get it. They are CRIMINALS, WHO HAPPEN TO BE DOCTORS! They have contempt for society; abuse their status, and our trust, 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, 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”, is a quote brought to my attention, some years back, by a medical professional committed to stopping this criminal activity, and is appropriate here. If one knows what the criminals, who happen to be doctors are doing – one can see how to stop them!
FIRST PUBLISHED: John Cooke Fraud Report, Jan/Feb 1997
