CommunityPam's House Blend

Another reason why our health care system is f*cked

While millions of people are underinsured or not insured at all, you’ve got corrupt doctors (and patients) working the system’s labyrinth of paperwork that makes it simple to perpetuate fraud to the tune of $1.3 billion. (NYT):

Twelve Blue Cross and Blue Shield plans, working with the F.B.I., said Friday that they had broken up an elaborate insurance scheme in which thousands of patients from 47 states were sent to California to undergo unnecessary surgical and diagnostic procedures, for which doctors filed more than $1 billion of fraudulent insurance claims.

Insurance executives and law enforcement officials said that surgery clinics in Southern California typically paid recruiters $2,000 to $4,000 for each patient who received a medical procedure. The patients, they said, received rewards in the form of cash or discounts on cosmetic surgery.

Daniel M. Martino, acting chief of the health fraud unit at the Federal Bureau of Investigation, said the payments to patients ranged from $200 to $2,000 each. Mr. Martino said the outpatient surgery clinics had billed more than $1.3 billion for services provided as part of the scheme, while insurers and employers had lost $350 million in claims paid to date.

…Steven E. Skwara, a fraud investigator at Blue Cross and Blue Shield of Massachusetts, said, “It’s astounding, the degree of brazenness of some of the folks perpetrating this scheme.” He spoke at a briefing with Blue Cross executives and federal and state law enforcement officials. William J. Feccia, an assistant district attorney in Orange County, said the patients traveled to California from 47 states.

Mr. Martino, the F.B.I. official, said insurers became suspicious when, for example, “50 people from Boston arrived in Southern California in a three-week period and filed claims for colonoscopies performed every other day.”

…The civil-suit complaint includes abundant detail drawn from insurance claims. In a typical case, an Arizona couple had three identical procedures at a clinic in Buena Park, near Anaheim, Calif. On Saturday, March 22, 2003, the husband and wife had endoscopies. They had colonoscopies the next day. On March 29, both had surgery for sweaty palms.

As compensation, some patients got cash and others received discounts on cosmetic procedures including a “tummy tuck,” breast enhancement and surgery to correct the sagging or drooping of eyelids, according to the insurers. The insurers said that doctors had fabricated symptoms and diagnoses for patients, but performed the surgical procedures. Thus, the medical records looked “legitimate or semi-legitimate,” Mr. Skwara said.

No patients were named as defendants. But Paul F. Brown, vice president of the Blue Cross and Blue Shield Association, a trade group that helped coordinate the investigation, said: “The vast number of patients knew exactly what they were doing. They did this to get money. They did not need the procedures.”

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Pam Spaulding

Pam Spaulding