Hospital Billing Fraud

I work in pediatric healthcare as a benefit specialist, I bill insurance and work with patients and their finances etc. Recently a patient of ours was dismissed from therapy because she was not improving (and we needed the spot for someone who would likely improve) though that was not mentioned to anyone but me. I felt that was unfair, as there are many children at our practice that do not have the potential to improve, but we still see them. I spoke to my employers and they told me it was fraud to bill insurance for medical services that were not likely to produce results or improvements in the patient’s condition. I understand that. However, the aforementioned girl was still turned away for therapy, and multiple patients still remain treated though its the same scenario. Should I speak to my employers about this or just do what I’m told? I bill the insurance, so am I commiting fraud? And is it my business that we are treating patients unfairly?
And yes SUSIE I can read medical progress reports written by our therapists and decipher whether the patient is improving or not… and besides that, my employer straight out told me of multiple patients that continue to be treated with no hope of progress.

medical office billing

ABC Demands ‘Answers’ on U.S. Health Insurance Ills; Ignores Canadian Problems
On Monday’s “Good Morning America,” the ABC program shifted into full advocacy mode as anchor Chris Cuomo investigated the health insurance industry. A week after the network promoted Michael Moore’s new documentary “Sicko” for over 21 minutes, co-host Diane Sawyer announced that, regarding health care, the program was demanding “some answers” with a new segment. According to Sawyer, the series is “for you, for all of us.” At the close of the report, the ABC anchor even pleaded with the audience for examples of nefarious health care companies:
Diane Sawyer: “…If you have an insurance company policy, a question that you want to raise, you want us to tackle something that you think the insurance companies are doing, you write to us. You let us know about it. ABCNews.com. We are on the case.”
And while Cuomo was “on the case” of a woman who had difficulty getting her insurance company to approve a much needed eye surgery, there has been no similar look at Canadian horror stories where government run health care made one woman with breast cancer wait three months for radiation treatment.
A report by the Canadian Fraser Institute found that the average wait time in that country to see a general practitioner was 17.7 weeks. One such incident found a woman waiting over three months to receive radiation therapy for breast cancer:
A similar lawsuit was filed in Quebec on behalf of 10,000 women with breast cancer who were forced into long waits for radiation therapy. Anahit Cilinger was one such patient. After having a lymph node removed in October 1999, she was put on a waiting list for radiation therapy. Three months later and with no end to the waiting in sight, she traveled to her native Turkey and paid $12,000 for the treatment.
Sawyer began the piece by proclaiming “a GMA commitment to take a hard look at the health insurance industry, to get some answers about those policies we keep hearing about, about what happens to sick people in a time of need.” One would assume that such a commitment would include investigating long wait times and other ramifications of adopting government controlled plans.
The case of Shannon Dagher, the woman featured in the GMA piece, is certainly sad. After being diagnosed with a rare eye disorder, Ms. Dagher needed a surgery to prevent blindness. Instead, her insurance company, Blue Cross, launched an investigation into her claim. (They ultimately payed for the surgery.) But while unfortunate, it’s no less real then that of Canadians who must resort to leaving the country to obtain treatment. Sawyer describe the “GMA Gets Answers” segment as a new feature, one that viewers should expect to see again. Hopefully, the ramifications of universal health care will also be discussed.
Michael Moore’s appearances promoting his new health care movie, “Sicko,” can be found here and here.
A transcript of the segment, which aired at 7:39am on June 18, follows:
7:20am tease
Diane Sawyer: “And we got word this woman’s health insurance company was threatening to cancel her coverage when she needed it the most, so GMA went into action. She’s not the only one and we’re going to get some answers.”
7: 30am tease
Sawyer: “And coming up in this half hour, this is one of those stories that has Americans up in arms about insurance companies. You’re going to meet a young woman whose doctors say that she needs surgery or she could go blind. But her insurance company threatened to cancel her coverage. Why? A controversial practice. This morning, Chris Cuomo’s on the case. It’s our new series ‘GMA Gets Answers,’ for her and for you, for all of us.”
7:39am
Sawyer: “Well, today we are announcing a GMA commitment to take a hard look at the health insurance industry, to get some answers about those policies we keep hearing about, about what happens to sick people in a time of need. Today, you’re going to hear about something called rescission. It is a controversial practice where insurance companies retroactively cancel the policy, often after you’re trying to make a claim. Chris Cuomo here again with the story of a young woman who faced a real crisis. Her sight was at risk.”
ABC Graphic: “GMA Gets Answers: Can Your Insurance Be Taken Away?”
Cuomo: “Absolutely. Now, as background, in this country there are thousands of people purchase their own insurance. They don’t get it through a union or through their work. The young woman you’re about to meet has a story that could happen to any of them. According to the industry’s, the insurance industry’s own estimates, thousands of similar rescission investigations into policy holders occur every year. And most of them lose their coverage as a result. It’s a frightening practices you might miss in the fine print of your health insurance policy. Shannon Dagher, a 22-year-old college student, says she was at the eye doctor for a check-up last November, one month after her new insurance policy kicked in when she received terrible news.”
Shannon Dagher (Denied Insurance): “I was diagnosed with a very rare disorder It’s called pseudo tumor cerebri. It basically looks and acts like a brain tumor.”
Cuomo: “Now, Shannon’s doctors say she needs surgery or she may go blind.”
Dagher: “I’m petrified of the thought of going blind. I’ve never been sick before in my life. And now, in the past six months, I’ve started to lose my peripheral vision and I’ll never get that back.”
Cuomo: “But instead of authorizing the surgery, here insurer, Blue Cross of California stopped processing her bills. The company, whose slogan is ‘Put the power of blue to work for you,’ instead launched and investigation into Shannon. It threatened to cancel her coverage if she had failed to disclose accurate information about her health, like headaches on her original application. But look at Shannon’s Blue Cross application. It lumps headaches with more serious conditions like epilepsy, paralysis, stroke, all in one question. She didn’t have any of those serious conditions, so she checked no.”
Dagher: “I never lied to Blue Cross on my application. At the time when I got the insurance, I had no knowledge that anything was wrong with me.”
Cuomo: “Legislators around the country are paying attention to this little known practice. The state of Connecticut has just passed a law to make it harder for health insurers to pass rescind policies.”
Connecticut Attorney General Richard Blumenthal: “These instances are hardly isolated or random. They are part of a pattern, a prevalent practice in this industry that very simply has to be stopped.”
Cuomo: “Just getting an insurance company to talk about rescission is not easy. It’s Chris Cuomo from ABC News. The best we could do was get Blue Cross on the phone. Why do you rescind a policy?”
Voice of Shannon Troughton (Wellpoint Spokesperson): “It’s an very important tool for us to address any identified issues of abuse or misrepresentation. Anyone who causes fraud in the system increases the costs of health care for all of our members.”
Cuomo: “We called eight other insurers. None would talk to us on camera and referred us to their trade group. Isn’t this about saving money for the company?”
Susan Pisano (America’s Health Insurance Plans): “Health insurers pay large claims and pay millions of dollars in claims every day.”
Cuomo: “Isn’t it a little fishy though that this rescission review process only begins after someone files a claim? Isn’t that suspicious? You know, why don’t you just do it when I’m applying in the first place, figure out whether I’m telling you the truth, like most industries. Here, I filed a claim because I’m sick and now you start looking at me?”
Pisano: “Well, here’s the way it- Here’s the way it work. Here is the way it works. A policy is rescinded only if someone could have known that the condition existed, they were asked about it on the application and they didn’t provide the information.”
Cuomo: “GMA went back to Blue Cross for clarification on Shannon Dagher’s case. What really surprised us was that shortly after we asked about Shannon’s policy, she learned that her investigation was complete and her policy would not be canceled. Then, Blue Cross denied Shannon’s policy had ever even been considered for rescission. It said in a statement to GMA, ‘Although she may have received a letter from us indicating a review was being conducted in the past, her policy was not rescinded. For you to report that this member’s issues are in any way linked to rescission would be erroneous and misleading.’ But Blue Cross had sent Shannon multiple letters telling her that the, quote, ‘rescission review process was under way.’ And while Blue Cross says it sent Shannon this letter telling her the review was complete, Shannon tells us she never got anything in the mail.”
Cuomo: “You’re the trade group. You’re speaking for them. They don’t want to talk to me about it. All they say is ‘Don’t say she was rescinded,’ but she was going through that review process. She wasn’t getting her claim paid.”
Pisano: “The companies we represent understand full well the impact of the process of rescission. It must be terribly disruptive, especially at a time when somebody is sick.”
Cuomo: “Like Shannon, who recently had to drop out of college because of her sickness and hopes her insurance company will not add any more to her troubles.”
Dagher: “To be accused of fraud when I have no defenses, when I’m sick and when I’m relying on the coverage that they promised me and that is due to me, it really shakes my faith in humanity and the good of people.”
Cuomo: “But there is some good news. The company authorized the surgery. Shannon, who has a basic policy with a high deductible, did not file suit. And just recently, Blue Cross of California did authorize the surgery that surgery that may save her vision, so remember that. And a California attorney is currently settling a class action suit against Blue Cross of California. The settlement will require the insurer to prove there was intentional misrepresentation before they can cancel a problem. The insurer is denying any wrongdoing but has agreed to revise and clarify the application policy filled out by potential clients.”
Sawyer: “So, after we started looking into it, word came-”
Cuomo: “Yes. We’re not saying cause and effect, but we started looking into it. All of a sudden they started saying that’s not even going on what you said was going on, but Shannon certainly thought it was.”
Sawyer: “Well, we want to let everyone out there know that if you have an insurance company policy, a question that you want to raise, you want us to tackle something that you think the insurance companies are doing, you write to us. You let us know about it. ABCNews.com. We are on the case.”

medical billing program

http://cosmos.bcst.yahoo.com/up/player/popup/?rn=3906861&cl=9122909&ch=4226716&src=news

- The only president ever impeached on grounds of personal malfeasance
- Most number of convictions and guilty pleas by friends and associates*
- Most number of cabinet officials to come under criminal investigation
- Most number of witnesses to flee country or refuse to testify
- Most number of witnesses to die suddenly
- First president sued for sexual harassment.
- Second president accused of rape**
- First first lady to come under criminal investigation
- Largest criminal plea agreement in an illegal campaign contribution case
- First president to establish a legal defense fund.
- First president to be held in contempt of court
- Greatest amount of illegal campaign contributions
- Greatest amount of illegal campaign contributions from abroad
- First president disbarred from the US Supreme Court and a state court

* According to our best information, 40 government officials were indicted or convicted in the wake of Watergate. A reader computes that there was a total of 31 Reagan era convictions, including 14 because of Iran-Contra and 16 in the Department of Housing & Urban Development scandal. 47 individuals and businesses associated with the Clinton machine were convicted of or pleaded guilty to crimes with 33 of these occurring during the Clinton administration itself. There were in addition 61 indictments or misdemeanor charges. 14 persons were imprisoned. A key difference between the Clinton story and earlier ones was the number of criminals with whom he was associated before entering the White House.

Using a far looser standard that included resignations, David R. Simon and D. Stanley Eitzen in Elite Deviance, say that 138 appointees of the Reagan administration either resigned under an ethical cloud or were criminally indicted. Curiously Haynes Johnson uses the same figure but with a different standard in “Sleep-Walking Through History: America in the Reagan Years: “By the end of his term, 138 administration officials had been convicted, had been indicted, or had been the subject of official investigations for official misconduct and/or criminal violations. In terms of number of officials involved, the record of his administration was the worst ever.”

**Selene Walter accused Ronald Reagan of rape 39 years after the alleged assault in the 1950s. No further information is available on this case. The Juanita Broaddrick case involving Bill Clinton was investigated by the congressional impeachment counsel. According to counsel David Shippers those conducting the interview “have assured me that she is the most credible witness that either one of them have ever talked to”

STARR-RAY INVESTIGATION

- Number of Starr-Ray investigation convictions or guilty pleas (including one governor, one associate attorney general and two Clinton business partners): 14
- Number of Clinton Cabinet members who came under criminal investigation: 5
- Number of Reagan cabinet members who came under criminal investigation: 4
- Number of top officials jailed in the Teapot Dome Scandal: 3

CRIME STATS

- Number of individuals and businesses associated with the Clinton machine who have been convicted of or pleaded guilty to crimes: 47
- Number of these convictions during Clinton’s presidency: 33
- Number of indictments/misdemeanor charges: 61
- Number of congressional witnesses who have pleaded the Fifth Amendment, fled the country to avoid testifying, or (in the case of foreign witnesses) refused to be interviewed: 122

SMALTZ INVESTIGATION

- Guilty pleas and convictions obtained by Donald Smaltz in cases involving charges of bribery and fraud against former Agriculture Secretary Mike Espy and associated individuals and businesses: 15
- Acquitted or overturned cases (including Espy): 6
- Fines and penalties assessed: $11.5 million
- Amount Tyson Food paid in fines and court costs: $6 million

CAMPAIGN FINANCE INVESTIGATION

- As of June 2000, the Justice Department listed 25 people indicted and 19 convicted because of the 1996 Clinton-Gore fundraising scandals.
- According to the House Committee on Government Reform in September 2000, 79 House and Senate witnesses asserted the Fifth Amendment in the course of investigations into Gore’s last fundraising campaign.
-James Riady entered a plea agreement to pay an $8.5 million fine for campaign finance crimes. This was a record under campaign finance laws.

CLINTON MACHINE CRIMES FOR WHICH CONVICTIONS WERE OBTAINED

Drug trafficking (3), racketeering, extortion, bribery (4), tax evasion, kickbacks, embezzlement (2), fraud (12), conspiracy (5), fraudulent loans, illegal gifts (1), illegal campaign contributions (5), money laundering (6), perjury, obstruction of justice.

HISTORICAL CONTEXT

- Number of independent counsel inquiries since the 1978 law was passed: 19
- Number that have produced indictments: 7
- Number that produced more convictions than the Starr investigation: 1
- Median length of investigations that led to convictions: 44 months
- Length of Starr-Ray investigation: 69 months.
- Total cost of the Starr investigation (3/00) $52 million
- Total cost of the Iran-Contra investigation: $48.5 million
- Total cost to taxpayers of the Madison Guarantee failure: $73 million

OTHER MATTERS INVESTIGATED BY SPECIAL PROSECUTORS AND CONGRESS, OR REPORTED IN THE MEDIA

Bank and mail fraud, violations of campaign finance laws, illegal foreign campaign funding, improper exports of sensitive technology, physical violence and threats of violence, solicitation of perjury, intimidation of witnesses, bribery of witnesses, attempted intimidation of prosecutors, perjury before congressional committees, lying in statements to federal investigators and regulatory officials, flight of witnesses, obstruction of justice, bribery of cabinet members, real estate fraud, tax fraud, drug trafficking, failure to investigate drug trafficking, bribery of state officials, use of state police for personal purposes, exchange of promotions or benefits for sexual favors, using state police to provide false court testimony, laundering of drug money through a state agency, false reports by medical examiners and others investigating suspicious deaths, the firing of the RTC and FBI director when these agencies were investigating Clinton and his associates, failure to conduct autopsies in suspicious deaths, providing jobs in return for silence by witnesses, drug abuse, improper acquisition and use of 900 FBI files, improper futures trading, murder, sexual abuse of employees, false testimony before a federal judge, shredding of documents, withholding and concealment of subpoenaed documents, fabricated charges against (and improper firing of) White House employees, inviting drug traffickers, foreign agents and participants in organized crime to the White House.

ARKANSAS ALTZHEIMER’S

Number of times that Clinton figures who testified in court or before Congress said that they didn’t remember, didn’t know, or something similar.

Bill Kennedy 116
Harold Ickes 148
Ricki Seidman 160
Bruce Lindsey 161
Bill Burton 191
Mark Gearan 221
Mack McLarty 233
Neil Egglseston 250
Hillary Clinton 250
John Podesta 264
Jennifer O’Connor 343
Dwight Holton 348
Patsy Thomasson 420
Jeff Eller 697

FROM THE WASHINGTON TIMES: In the portions of President Clinton’s Jan. 17 deposition that have been made public in the Paula Jones case, his memory failed him 267 times. This is a list of his answers and how many times he gave each one.

I don’t remember – 71
I don’t know – 62
I’m not sure – 17
I have no idea – 10
I don’t believe so – 9
I don’t recall – 8
I don’t think so – 8
I don’t have any specific recollection – 6
I have no recollection – 4
Not to my knowledge – 4
I just don’t remember – 4
I don’t believe – 4
I have no specific recollection – 3
I might have – 3
I don’t have any recollection of that – 2 I don’t have a specific memory – 2
I don’t have any memory of that – 2
I just can’t say – 2
I have no direct knowledge of that – 2
I don’t have any idea – 2
Not that I recall – 2
I don’t believe I did – 2
I can’t remember – 2
I can’t say – 2
I do not remember doing so – 2
Not that I remember – 2
I’m not aware – 1
I honestly don’t know – 1
I don’t believe that I did – 1
I’m fairly sure – 1
I have no other recollection – 1
I’m not positive – 1
I certainly don’t think so – 1
I don’t really remember – 1
I would have no way of remembering that – 1
That’s what I believe happened – 1
To my knowledge, no – 1
To the best of my knowledge – 1
To the best of my memory – 1
I honestly don’t recall – 1
I honestly don’t remember – 1
That’s all I know – 1
I don’t have an independent recollection of that – 1
I don’t actually have an independent memory of that – 1
As far as I know – 1
I don’t believe I ever did that – 1
That’s all I know about that – 1
I’m just not sure – 1
Nothing that I remember – 1
I simply don’t know – 1
I would have no idea – 1
I don’t know anything about that – 1
I don’t have any direct knowledge of that – 1
I just don’t know – 1
I really don’t know – 1
I can’t deny that, I just — I have no memory of that at all – 1

ARKANSAS SUDDEN DEATH SYNDROME

- Number of persons in the Clinton machine orbit who are alleged to have committed suicide: 9
- Number known to have been murdered: 12
- Number who died in plane crashes: 6
- Number who died in single car automobile accidents: 3
- Number of one-person sking fatalities: 1
- Number of key witnesses who have died of heart attacks while in federal custody under questionable circumstances: 1
- Number of unexplained deaths: 4
- Number of northern Mafia killings during peak years of 1968-78: 30
- Number of Dixie Mafia killings during same period: 156

medical claim billing

I have a question regarding BAQ(BAS/BAH).

When is a service member not eligible to continue receiving BAQ with spouse?

We have been separated for 10 years.

We became divorced in 2005 and he is still collecting BAQ with spouse. He is an E-9.

We have 2 children together he has no visitation.

He is stationed in Tennessee and I live in California.

He is attempting to avoid resolution of his retirement by stating that we were married for 9 yrs, 7 months.

He was not paying guideline child support (CA) for many years until October 2005.

I have many unpaid medical bills for our children and he will not contact tricare to help with billing issues.

He tricked me into allowing him to claim me and our kids on previous tax returns, stating that I had to or he’d lose the extra money from VHA/BAQ (I have copies of his tax records from 2000).

Is this proper for an E-9?

Your help would be greatly appreciated

medical insurance billing and coding