Friday, March 8, 2013

Why Isn't This Fraud?

     There are many unpaid insurance claims for which I am waiting to be reimbursed--claims for office visits and services I provided to patients before I closed my clinic.
     I get stacks of mail each week from the insurance companies that are supposed to be paying, i.e., taking responsibility for covering the cost of patients' medical care, patients I saw and treated, patients who pay their monthly premiums and think the insurance companies are doing their part, too.
     Are insurance companies paying?  What do you think?
     The letters I get are computer-generated and without signatures, contact information, or evidence of any human life-form-- that is, people who might be able to explain and justify the absurd "denial of payment notices I'm being sent  Here's an example: 

     "Dear Provider:
          We are in receipt of your claims for services.
          Blue Cross has approved $524 for services for the above-named patients.
          However, we have determined that you were overpaid by $586 for other patients, who are not named here, and who were seen by you in the distant past--in some cases more than a year ago.  We decline to give you information about these overpayments, but be assured, we are correct.
          Therefore, we have offset the approved payment with a take-back for the overpayment, and have enclosed herewith an invoice for $62, for you to pay.
          Please remit this payment to Blue Cross immediately.
                                                                               Your Florida Blue!"

     In other words, not only are these insurance companies not paying for my services, but they're insisting I pay them.
     Recall that insurance companies set all fees, and doctors are required to accept or decline them.  If they decline the fee schedule, doctors can't see patients as "in network" providers.  Patients who choose out of network doctors must pay substantially more for medical care;  in some cases they can't be seen at all, except as cash-paying patients.
     If insurance companies establish fees, and pay when they feel like it, and pay whatever portion of the fees they choose--how can they be making "overpayments"?  In none of the cases have records on the patients been requested, so the so-called overpayments can't follow upon an audit of office notes that show services weren't equal to charges.
      Blue Cross doesn't provide information about which patients or services were accidentally "overpaid," or when, or how much per patient, or why Blue Cross made a mistake in paying correctly amount in the first place.  My billing staff have said that there are no cases in which an "overpayment" was posted in the past, therefore there were none that needed to be offset.
     Blue Cross, like other insurance companies, maintains a website that lists "allowables"--the amounts it deems the doctor should be paid for each covered service.  Comparison of our charges and payments shows not that we have been overpaid, but that we have been consistently underpaid.
     Instead of payments for my services, I get theset incomprehensible letters like this, with an expectation that I'll pay Blue Cross.  I have a "time-frame" within which to "re-pay" the "over-payments," or the bill will accrue interest.  Has the world turned upside-down?
     The logical thing is to call Blue Cross and find out how the company has calculated overpayments when I can't find any.  My billing and coding have been accurate, the patients were seen and treated, the documentation is in the charts to prove it--but I can't get paid.
     To make matters worse, the form-letters don't have a Blue Cross return address.  They come from an intermediary company, named Mellon, which operates like a collection agency.   The representatives at Mellon are collection agents:  they know  nothing about medicine, billing, claims or overpayments, and they don't want me wasting their time with grievances.

     "Please show me how Blue Cross 'overpaid' me, and when, and on which patients!"  I say, impatiently.
     "Ma'am, I'm trying to help you.  Don't raise your voice."
     "Can you identify which patients and which office visits are involved?"
     "That information is not available to me."
     "Well, then, who has it?"
     "Let me put you on hold, and see if I can transfer you."
     "Wait, wait...!"
     Click, click, click.  Disconnect.
      I call back.
     "I've already been placed on hold three times, and have been on the phone for 40 minutes."
     "I'm sorry for the inconvenience."
     "I don't want an apology, I want information."
     "I said, I'm going to try to help you.  Please hold..."
     "Can I help you?"
     "Yes...this is my third call about this letter."
     "Now, please tell me what you need."
     "I have a bill from Blue Cross, sent by Mellon, saying I owe money, which can't be the case.  In fact, I should be getting a payment from Blue Cross."  
     "Let me check your record.  You owe Blue Cross for overpayments."
     "No, I don't.  Can you find out who the patients are, the ones Blue Cross claims to have 'overpaid me for.'"
     "That information isn't available to me."
     "Who has it?"
     "You might call Blue Cross."
     "I did.  The representative there couldn't track the claims that were 'overpaid.'"
     "How soon can you remit your payment to Mellon?"
     "I don't believe I owe Mellon or Blue Cross."
     "Our records indicate that you have a balance due."
     "No, I don't!  That's the problem."
     "Would you like to pay by credit card, or check-by-phone?"

     Why isn't this fraud?  Why isn't anyone regulating insurance companies?
     I asked my new billing specialist, who is assisting me at collecting past balances from Blue Cross, Tricare, Aetna, Humana, Medicare...dozens of insurance companies who run the show in American medicine--What's going on?  
      She has seven years of medical collection experience.  She should know.
     "They get away with this because they're insurance companies," she answered.  "It's impossible to get them to be accountable for what they do."
     How many battles can one person fight at a time?
     It's only money, I say,  comforting myself as I walk out to the garden, with my discontent and my hoe.
     But it's money patients and their employers are paying in monthly premiums, and money Blue Cross isn't paying doctors for services, because they can get away without paying.
     I'm so glad I won't be playing these games any more.
     I yank out some weeds.
     I'm so glad I'm finished with American medicine.
     I detangle a few knots of bahia grass.
     I hate this country.
     No, I don't.  I love it.  That's why I'm going to change things.
     Hello, chickens.  Have some chickweed.
     Thank God for chickens, and their uncomplicated lives. 
     No wonder Blue Cross posts billions in profits every year.  No wonder all the other insurance companies have followed suit, manipulating money out of patients, doctors, and hospitals.  If we doctors and patients had lobbyists knocking on the doors of congresspeople every day, maybe we could post profits, too.
     Wait a minute.  Don't we have representatives in Congress?
     Where are they?


  1. I can not seem to get over the notion that perhaps some of this idiocy started when you left Shands...Though I do not know the why, anymore than you do.

    1. It was more than ten years after my resignation from University of Florida's College of Medicine, where I had been Assistant Clinical Professor of Medicine in the Community Medicine and Family Health department for six and a half years. I can't see how that hallowed institution could be connected to the government's actions against me, although I would have been protected from government action, to some extent, had I remained under the University's umbrella--which is why many good doctors stay at UF, and don't consider private practice. Hence, my sad farewell, "Solo Docs, So long!"

  2. We, the people, have very few representatives in Congress. Could be that our 'should have been' representatives were forced by circumstances to do something else and are now wondering why their opponent won the people's vote.

    Then again, who has complained?

    1. I am going to find out how many true "representatives" we have in Congress, very soon. I have written to every Florida representative, and hope to meet with as many U.S. reps as possible, in the near future. Unfortunately, many have already told me that I'm either "outside their districts" or that they're "very busy" and "don't have time right now in their schedules." I am learning how difficult it is to effect change.

  3. Without saying it, insurance companies want doctors to provide the least amount of care that would preclude malpractice (in their judgement).

    1. Insurance companies don't care about malpractice, because they don't have to pay for the consequences. They make it difficult for doctors to do the right thing for patients, by prohibiting tests and treatments that seem too expensive. It goes without saying that insurance companies, being corporate entities, don't care one iota about their "covered clients"--not as human beings. What they care about is profits. We can't criticize them for this--they're the monsters we have allowed them to be. But we have to find a way for humanism to override corporate aims.

  4. More specifically, insurance companies do not want doctors addressing the health of clients, they want them to respond minimally to their primary presenting condition. Ironically, major hospitals and surgical practices do not experience the same billing hell that independent family and urgent care doctors face.

  5. Major hospitals and corporate medical practices have lawyers and MBA's on retainer, which solo doctors can't afford. These lawyers act as a deterrent. This is what makes practicing medicine so sad. When you have to purchase a battalion of lawyers and businessmen to run a clinic, you can't run a solo clinic.

    1. Many construction companies suffer the same consequences, as retainers for lawyers are at times extreme, and I do not have to tell anyone about the bottom line...along with the fact all the lawyers seem to be in cahoots as to who gets what and when...and you are right when you say it is difficult to make a difference as to change...especially positive change. People need, must wake up to this intrusion into the very freedom the Constitution is meant to protect us from.

  6. We have a love-hate relationship with lawyers, in the United States. Nowhere else in the world are lawyers considered so necessary to the smooth (?) functioning of society.