Lasik Eyes Surgery - The New York Times Medical Billing Fraud Story

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The New York Times Medical Billing Fraud Story

doctor_my_eye@msn.com

2005-03-19, 6:24 pm

For those of you who missed this in the NYTimes this morning...

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March 12, 2005
Huge Billing Fraud Is Cited by Health Plans at California Clinics
By ROBERT PEAR

WASHINGTON, March 11 - 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.

The Blue Cross and Blue Shield plans filed a civil lawsuit on Thursday
against nine surgery clinics, 21 doctors and 13 people described as
owners, employees or administrators of the clinics. The Justice
Department and the district attorney in Orange County, Calif., have
filed criminal charges against some of the defendants.

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 lawsuit, filed in Federal District Court in Los Angeles, also
stated that the plaintiffs - Blue Cross and Blue Shield plans - were
puzzled to see "clusters of employees from the same workplace" going to
California for the same treatments.

The recruiters often persuaded co-workers to join the scheme. Patients
were recruited from small and medium-size businesses, as well as units
of corporations like Textron.

In the lawsuit, the Blue Cross plans said that the recruiters located
patients, persuaded them to have the procedures, verified that they had
insurance coverage and helped arrange transportation to California.

The F.B.I. and the Blue Cross executives said that many patients who
traveled to California received three or more procedures in a week. The
most common combination was a colonoscopy, to examine the lower part of
the gastrointestinal tract; an endoscopy, to examine the upper part of
the digestive system; and an unusual procedure to treat "sweaty palms."

Mr. Martino said the last procedure, known as a thoracoscopic
sympathectomy, posed potential risks to the patient because it involved
collapsing a lung and deactivating a nerve near the spine.

Repeated efforts to obtain comment from the doctors and clinics on
Friday were unsuccessful. Millennium Outpatient Surgery Center was
named as a defendant in the civil suit filed by Blue Cross and in the
criminal case filed by the United States attorney in Los Angeles.
Fabiola Sanchez, a receptionist, answered the telephone at the number
listed for Millennium. She said that a new clinic, Park Center
Outpatient Surgery, now occupied the site, but was not taking patients
because "we don't have any doctors yet."

In Irvine, Calif., at the office of a doctor named as a defendant, an
employee expressed surprise and said the charges in the lawsuit "make
no sense." Another doctor defendant, in Tustin, Calif., refused to take
a phone call seeking comment.

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."

The Orange County district attorney, Tony Rackauckas, said, "Health
care fraud victimizes each of us because it raises everyone's health
insurance rates."

"At least 1,600 employers had employees who were involved in the fraud"
at one clinic, Mr. Rackauckas said. More than 5,000 patients had
unnecessary surgeries, he added.

County prosecutors said that owners of the clinic in Buena Park had
billed insurers for almost $97 million and tried to hide their
identities by creating shell corporations with different addresses and
different tax identification numbers.

Mr. Martino said the scheme had apparently first developed among
Vietnamese patients, who learned of the clinics at nail salons and from
newspaper advertisements. It spread to "the Hispanic community in
California" and to assembly-line workers at companies around the
country, he said.

Copyright 2005 The New York Times Company

serebel

2005-03-19, 6:24 pm

What the heck does this have to do with laser surgery? Oh, what a
surprise, insurance fraud. This never happened before. Where do you
live,"Mayberry"?

SErebel

Ragnar

2005-03-19, 6:24 pm

Actually, I think he lives "over to Mount Pilot.. nextdoor to Thelma
Lou"

Serebel is right in pointing out that people are abusing this group
with their non-laser surgery related babble.

LVI in Florida is back to publishing their crooked ads again. This
time they are saying $499 instead of $299. They are still as crooked
as ever. They are the masters of bait-and-switch and continue to get
away with it.

On 13 Mar 2005 19:36:24 -0800, "serebel" <serebel@aol.com> wrote:

>
>What the heck does this have to do with laser surgery? Oh, what a
>surprise, insurance fraud. This never happened before. Where do you
>live,"Mayberry"?
>
>SErebel