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 multiple functions:

1) It inflates the insurance companies potential liabilities
2) It creates the impression of provider misconduct by targeting high profile doctors.
3) It frightens doctors away from delivering a Normal Standard of Medical Care
4) The insurance company now becomes the gatekeeper, but who is the insurance company's gatekeeper ?
5) Decreases the availability of quality health care delivered to patients nationwide
6) Enables/Provides the reasoning for the Rationing of Health Care in the U.S.A.
7) Uses the variables in HIPPA medical coding to create double billing

The physicians who have the highest dollar billing in each insurance category and company can be accused of fraud.

In the 1970's when I was a Methods and Procedures Analyst for Colonial Penn Insurance Company my primary assignment was Special Projects. One of the Projects I worked on for three years was separating the AARP membership premiums from the Colonial Penn Insurance Premiums. The real problem was understanding how the funds had gotten co-mingled.. This work took over three years. We even found microfiche that had been stored off site on a container in the ocean,which had to be hung from a clothes line we had put up throughout our dept. As the microfiche dried, we reprocessed and enhanced it until it was legible, Once all the systems analysts understood the computer error, many hundreds or if not thousands of hours went into reprogramming the computers with a sub-routine to separate the files that contained the individual fees and allocate them to the correct legal entiies..See references below:

"In 1978, after being fired by Davis, Executive Director Harriet Miller (who eventually became mayor of Santa Barbara, California) filed a $4 million suit leveling many of the same charges, contending that control of the organization rested in the hands of Colonial Penn. A 60 Minutes exposé demoralized AARP workers, members, and volunteers, and Davis left the organization in February 1979. AARP settled Miller's suit for $480,000 and began inviting competitive bids for its insurance business in 1981. Prudential Insurance Co. won the contract and devoted a staff of 4,500 to the project."

With HIPPA in place, the government now had an additional tool to attack doctors and help maintain health care rationing. Now insurance companies saw their advantage by helping federal government agencies. The insurance companies in return where given the opportunity to reach an agreement with the Unites States government.

To the best of my knowledge and based upon my project documentation; the following information was obtained on a first hand basis.

In a well documented case called U.S.A. v. Lauersen; the parties went to trial as the following entities paid huge sums of money to the Federal government for Medicare/Medicaid Fraud found within their companies.These type of agreements are called Corporate Integrity Agreements which serve as a civil fine in lieu of going to court in a criminal prosecution. Neither the Court or the Jury were ever made aware of these agreements as Dr. Niels H. Lauersen was on trial. Since many of these entities were mentioned during his trial, didn't the Court and the Jury have a Constitutional Right to know about this pattern of activity?

This serves to prove the adage that ""Justice is lame as well as blind, amongst us"; Thomas Otway - 1652-1685.

Blue Cross/Blue Shield of New York #1 $203,000,000.00
Blue Cross/Blue Shield of New York #2
Blue Cross/Blue Shield of Connecticut
Blue Cross/Blue Shield of Massachusetts
Lenox Hill Hospital $23, 757.00
Mount Sinai School of Medicine
Blue Cross/Blue Shield/NY/Audit #3
New York Cornell Hospital $17, 762,539.00
Columbia University
St. Vincents Hospital $2,261,155.00

Total
$205,261,155.00

What is the motivation for these types of attacks and co-operation? NOT TO GO TO JAIL and/or to make sure to find a fall guy to take the rap.

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, we 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

By assigning new claim numbers to existing claims being processed, any insurance company can create a paper trail of supposed fraud when none exists. Empire Blue Cross/Blue Shield had signed a CIA or Corporate Integrity Agreement with the Unites States government agreeing to repay $200+ Million Dollars in over payments back to the institutions.

Blue Cross Blue Shield Error Analysis in Claims Processing

In the case of USA v. Lauersen the following was uncovered.

BC/BS decision to inflate Dr. Lauersen’s submissions creating the appearance of impropriety in the amount of $58,440.00 when the correct amount due the doctor was $34,000.00. THEREBY DEMONSTRATING THAT INSURANCE HEALTH CLAIMS PROCESSING IS FRUITFUL FIELD FOR FRAUD WHICH ALLOWS INSURANCE COMPANIES TO DISCREDIT DOCTORS RESULTING IN LOWER STANDARDS OF MEDICAL CARE AND REDUCED COSTS FOR INSURANCE COMPANIES.

This error methodology 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 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 being used as evidence in cases brought before 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 fraudulent claims generated by local, state or federal governments in conjunction with the insurance companies.

To find out what our government knows read the report below about these medical billing errors:

DEPARTMENT OF HEALTH AND HUMAN SERVICES, OFFICE OF THE INSPECTOR GENERAL, OFFICE OF EVALUATION AND INSPECTIONS, REPORT ON MEDICARE BILLING SOFTWARE AND PROCESSES USED TO PREPARE CLAIMS (OEI-05-99-00100; 3/00). NOTE THE BIBLIOGRAPHY CONTAINS 3 REFERENCES FROM 1978-1981 AND ONE REFERNCE FROM JUNE, 2, 1999.

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