Insurance, Again. The s**t got real.

Photos of an acupuncturist in a prison jumpsuit, bond reduced to $455,000, facing charges of racketeering, insurance fraud, engaging in an organized scheme to defraud, patient brokering, and unlawfully waiving copays and deductibles. It’s bad for the profession.

It’s worse when the acupuncturist taught insurance billing seminars.

Whether or not she is ultimately found innocent, I’m sure none of us want to be in her shoes. Let’s learn what we can from the case, and from the discussions about it happening on social media and elsewhere.

(Here are additional stories about the case: Indian River Meeting MinutesMarch 2017August 24, IRC MemoFlorida CFO, September 13)

My takeaways –

  • There are wonderful, respected, kind, people who engage in criminal activity. Encomiums about the accused show us humans aren’t one-dimensional, but are irrelevant to guilt or innocence.
  • Insurance billing is no game, despite books, seminars, and conversations presenting it as one.
  • As a profession (the community acupuncture folks being the main exception), we haven’t accepted the conflict between wanting people to get as many acupuncture treatments as we think appropriate/they desire, earning what we “deserve”, practicing in our preferred style, and the overall health care economy. We grabbed insurance as the savior. It isn’t.
  • It is easy to rationalize wrongdoing. Practitioners justify creative billing to help their clients or counteract an unfair system. That’s bad for our profession, personally risky, and, because “insurance money” comes from people buying insurance, ultimately costly to anyone buying insurance.  If a plan doesn’t cover acupuncture for depression, explaining that to your clients, and giving them a discount if you’d like, is honest. Believing that the insurance company is forcing you to figure out a way to “treat them for pain so it gets covered” is dishonest.
  • If you want to advocate for better coverage, be prepared with data to show the economic benefits. Do you want your premiums to cover other non-medically necessary choices? Who should decide?
  • We need to be honest when discussing the efficacy and cost of acupuncture. Many practice websites, and much of our lobbying for increased coverage, refer to a course of treatment of eight to twelve visits. If an average of almost forty treatments/year, as in this case, is appropriate “for today’s complex patients” (as many commenters stated) we need to own that. If it varies based on condition (of course it does), let’s make sure we let patients and insurance companies know. If you are treating for a complex condition, but code for a simple one to facilitate reimbursement, you’re skewing the data about acupuncture efficacy.
  • There are lots of acupuncturists eager to give definitive answers to questions outside their area of expertise. Having a successful insurance-based business does not make one an expert on insurance law.
  • Our burdensome systems for approving CEU/PDA classes don’t provide quality control.
  • Having demanded entry to the system, we owe it to ourselves (as consumers and providers) to speak up when we see wrongdoing. We need to acknowledge that our colleagues who review charts and advise insurance companies are necessary if we are going to be part of the system. It’s a bad sign when those within the profession who work to protect the consumer are dismissed as the enemy. The insurance companies will find problems even without our participation.
  • Context is important when determining legality. Patterns of individually legal actions (in this case, waiving co-pays was permissible) can add up to illegal activity.

Here’s more on Health Care Fraud – from an investigator.

Being a health care provider is serious business. Participating in the insurance system is serious business. Let’s be careful out there.

 

 

 

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© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2018. Unauthorized use and/or duplication of this material without express written permission from Elaine Wolf Komarow is prohibited. Excerpts and links are encouraged, provided that full and clear credit is given with specific direction to the original content.

13 thoughts on “Insurance, Again. The s**t got real.

  1. And this is just ONE of the MANY reasons I don’t accept insurance at all. It is a racket, in my opinion. In order to get paid what we normally would get paid by the non-insurance patient, the prices are raised up to “cover costs”. So HOW is this saving our patient’s money? AND couple THAT with the fact that there are NO doctors (or acupuncturists) on ANY health insurance boards!! Excuse my gall, but what gives the insurance the right to tell ME (or ANY DOCTOR) what is right for MY patient. We all know some patients need a few visits, as their body just seems to “get it”, and others need LOTS of visits, as the problem has make a nice home in their body. We didn’t go to school for a long time to have someone who has NEVER been trained in our industries, tell us what is appropriate treatment for our patients.

    Even if they DO accept the course of action we choose for our patient, they can MANY TIMES take up to 8 WEEKS to pay us! That’s insane.

    I pray this person that was arrested gets the situation positively resolved. But for me and my practice, I choose to keep my rates very reasonable, work with people, even use a hardship waiver & sliding scale, because I want to HEAL people and improve their lives. I personally know of DOCTORS who are no longer taking insurance as well because they too are fed up with the bureaucratic interference in their business with their patients.

    Blessings all,
    Renee

    • I don’t think the point of insurance has been to save patients’ money, it was to cover unexpected costs that would be out of reach of the average consumer. Just as car insurance helps us when we have accidents, but doesn’t cover regular maintenance.

      I’m not sure what you mean by no MD’s on acupuncturists on Health Insurance Boards – certainly companies do employ folks from those professions to advise.

      Insurance companies need to make sure the money they collect can cover the services they are obligated to cover. Part of that process is determining what treatments will be most cost effective and most beneficial. If they are the ones paying they do have the right to determine what services to cover.

      Ultimately, though, I agree, if you don’t want to work under the terms the insurance companies offer, it’s best to avoid them completely and find ways to practice that work for you. I’m glad you’ve found a way to may it work.

  2. also what Jill was teaching is what we needed to know I followed her instructions and my paper work was all in order that is what got me through it did you know all someone has to do is put in writing a complaint against you and an audit must be done

  3. What about due process INNOCENT until Proven Quilty We tend to eat our own with out the facts so far you have heard one side this destroys people and it cost real money and lots of it to defend yourself. I spent 3 years and 200,000.00 to protect myself from lies in the end I was cleared all people remember is I was accused on matter I did nothing wrong. Watch out when you point the finger it may come back to bite you even if you have done nothing wrong

    • Anne, perhaps re-read the post. I state that she may be innocent. But that I assume we’d want to learn what we can from this case. Ideally, our practices would be such that any review of our records wouldn’t lead to our arrest. Shouldn’t we learn from the problems we’ve run into?

      • yes we should learn in my case it still cost me 200,000.00 for lawyers and almost 3 years to prove I did nothing wrong and yes they did audit me over and over and over and found nothing the fact that one person can do this to you is wrong because it can happen to anyone the reason I did nothing wrong is because I did everything Jill taught me in her classes and all my paper work was in order

        • Anne —

          I think you are proving one of the points I am trying to make. It sounds as though some of what Jill was teaching was not actually what we should have been learning. That it cost you so much to prove you had done nothing wrong is not comforting. What do you mean “one person can do this” – who is the one person? The CFO of Florida wrote about the investigation into Jill’s practices and found plenty wrong. This is a good opportunity to learn how to avoid the hot seat. Not insist that, because 200K later you were able to escape means everything was a-ok.

      • YES IT WAS A OK and it only takes one person to file complaint and you are guilty until you prove your self innocent lawyers do not work for free and when you have criminal charges filed you must protect yourself and no insurance company will touch you in my case it was an ex husband who’s goal was to destroy me what I am saying is do not believe every thing you read or hear this may be a new concept people lie and we all have something to learn from this their are no victims that does not take away from humanity and support for what they are going through A

    • Also, I’m not pointing any fingers. I don’t even mention the practitioner’s name. The story was in the news and widely discussed on social media.

  4. It’s about time. For many years I have “heard” the stories of egregious cheating/fraud/scamming, not only from my colleague-friends, but from patients, on electronic bulletin boards, and other sources. Not witnessing it first hand, I didn’t feel I could contact the authorities with any credibility. And now, this is a lesson for us all; especially for those who stay up nights thinking how best to “work” the system by shading the truth.

    • The practitioner in question has (or had) a decent presence on social media, and through her teaching (she taught insurance billing at at least one of the FL schools) she had lots of friends online. In the early days of this story, she presented her troubles as being the fault of a disgruntled employee who had reported her. It was interesting to see how quickly the sense “of the room” was that yes, darn that employee, the nerve! And also that none of those defenders seemed to consider that, if things were being done by the book, there would be nothing there to be revealed.

  5. quotes I love: “Our burdensome systems for approving CEU/PDA classes don’t provide quality control.”

    and

    “It’s a bad sign when those within the profession who work to protect the consumer are dismissed as the enemy.”

    • Thanks!

      It seems we spend a lot of energy being very rigorous about things that might not need that level of concern. And then being upset when people put any effort into verifying things that actually could use some attention.

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