| Daniel Osborne is an authority on health care fraud, abuse and compliance. He works with providers to increase practice certainty through educational programs; working groups; practice audits; compliance programs; and general consulting services. |
In mid-September 2003, I attended the International Association of Special Investigative Units (IASIU) 18th Annual Seminar on Insurance Fraud in Orlando, Fla.1 The event, purportedly planned to provide the best education available on insurance fraud, covered more than 30 topics taught by professionals from public and private sectors. The seminar opened with an announcement by the IASIU president that the seminar's focus would not be on property-related claims issues, as was the case in the previous 17 gatherings, but on health care fraud. This refocus was brought on by a paradigm shift within the insurance industry that the biggest loss as the result of fraud is not from property (arson, theft, etc.) claims, but from fraudulent health care claims.
In actuality, the seminar focused little on the overall problem of health care fraud in liability claims, but focused clearly on the activities of chiropractors, with a primary emphasis on multidisciplinary practices and mobile electrodiag-nostic testing labs. After the seminar, one could have left with the belief that health care fraud and chiropractic were synonymous, as the speakers continually attacked chiropractors, with no care taken to remind their audience that not all chiropractors engage in fraudulent activity! It was quite apparent that the speakers had an US (insurers) against THEM (chiropractors) attitude. Clearly, the chiropractic profession was not presented as a viable part of the solution in combating fraud and a member of the health care fraud fighting team, but as the target of it!
In one presentation, after the speaker failed to mention the chiropractic examining board's role as a source for investigators to report suspected chiropractic fraud, I informed him of this oversight and requested he inform his audience. My request went unanswered.
In another presentation, a speaker from Washington State did mention the chiropractic board as a potential source for combating fraud involving chiropractors, but added that it did not do any good until now, "because we have beat them up." It was ironic to listen to the silence and comments of these speakers in a hotel located just across the street from where the Federation of Chiropractic Licensing Boards (FCLB) had held its annual conference just months earlier. The FCLB meeting included discussions on health care fraud/abuse trends and efforts to combat the fraud!
The truly amazing aspect of the entire seminar was the unqualified and inaccurate information presented by the speakers, including the following:
- An attorney provided the definition of a "worthless" diagnostic test.
- No billing code is available for Current Perception Threshold test.
- CPT defines proper billing for technical components of services/procedures rendered.
- HCPCS codes are for hospitals, and chiropractors can't use them.
- Chiropractors can't perform 99205 level exams under any circumstance.
- All mobile diagnostic tests do not give good raw data.
- Improper coding to report a CPT code and indicate service provided for all diagnoses reported.
- Consultation codes can only be used if referred from another discipline.
- ACA rules preclude a chiropractor from doing a CMT and E&M service on the same day.
- The use of any CPT code ending in 99 is a red flag for fraud.
- If a chiropractor uses a CPT code ending in 99, he/she must send a letter to the insurance company explaining why, out of all the available codes, that code was used. A letter must also be sent to the AMA explaining that the code was used.
My purpose in attending this seminar, attended by more than 1,000 SIU representatives of insurance companies throughout the U.S., was to learn of new fraud trends in health care, methods to identify the fraudulent activity, and current efforts to combat the fraud. I wanted to educate myself so I could better consult current and future clients. However, after attending the seminar, I found no substantive information to meet my goals, and left with surprise that the property and casualty insurance industry did not appear, based on the presentations, to be any more sophisticated in investigating health care fraud then it was some seven years ago, when I left its investigative ranks.
The attitude of the presenters at this conference, and the vast majority of the attendees, clearly demonstrated the insurance bias toward chiropractic. How should the profession deal with these misperceptions? I urge chiropractic leaders to attend these programs and build relationships with association officers and presenters. When your presence and active participation in an organization is known, attitudes change. This battle is winnable only if we are actively involved on the battlefield!
Reference
- For complete information on IASIU and its 2003 seminar, visit www.iasiu.com.
Daniel Osborne, MS
Ponganoxie, Kansas
cccpfc@aol.com
