MPN and capitation payments, how it can affect your recovery

Some argue, that the insurance claims fraud that takes place in a fee-for-service health care market, is eliminated with a system of capitation. A health care provider no longer has to file a claim but is compensated according to the established fee schedule. However, a California State Senate report titled “Fraud and Abuse in the Health Care Market of California" exposes the potential for a different type of fraud: underutilization fraud, where the health care provider withholds treatment as much as possible to maximize profits, given the low capitation payments. 

According to the report, capitation “gives providers the incentive to reduce the quality of care. What many people do not realize is that capitation passes on the insurance function, namely the risk, to the person or entity who receives the capitation and provides the medical service.”

 As the medical provider now assumes the risk of delivering care to workers, he needs to mitigate that risk by spreading it across a larger patient base. But with a larger group of patients, the provider, out of necessity, must spend less time in treating each patient. “The provider is put in a difficult situation. Fraud can then occur when a provider attempts to make money by cutting corners in the delivery of medical care.”

Claims and Underutilization connection in California

Workers’ compensation insurance fraud is most commonly associated with false claims; scams made by patients claiming mythical injuries or unethical medical providers inflating their treatment costs or billing insurers for services that were never actually provided. False claims in insurance fraud is a problem that can occur at any layer of the health care system, including provider organizations, purchasing cooperatives, employers, HMOs and indemnity health insurers. 

False claims insurance fraud encompasses a wide range of deceitful activity; such as an employer lying on an application to get better insurance rates, misrepresentation by purchasing cooperatives to guide buyers to inferior plans, insurance company salesmen promising benefits that a coverage plan doesn’t include and a patient lying about his medical condition to get prescription drugs that are then sold on the black market. 

While claims fraud attracts the most attention of all types of false statement insurance fraud, there are multiple types of false claims and other false statement techniques, as follows: 

• Unbundling - In this type of fraud the medical provider submits separate claims for a single treatment, raising his profit for the procedure.

• Upcoding - A provider sends in a bill to the insurer for a procedure that is much more expensive than the one actually performed.

• Billing for Services Not Provided - Fraud that goes a step further than upcoding, a provider submits a claim for a treatment that the patient never received.

• Exclusion of Covered Benefits - This is a scheme by unscrupulous providers, who tell a patient that the treatment they need isn’t covered by their insurance when it actually is. The provider then offers to provide the services at a discount if the patient pays directly.

• False Coverage - False coverage fraud is a scam run by “fly-by-night” insurance companies that take an employee's premium payments but then fail to pay legitimate claims, leaving the patient on the hook with the medical provider.

• Credentials Falsification - The false credentials ruse occurs when a medical provider or facility presents credentials that they haven’t earned and provide services they’re not qualified to perform, putting the patient’s health and life at risk.

One of the most egregious cases of false claim insurance fraud was perpetrated by Hospital Corporation of America (HCA), the largest private operator of health care facilities in the world. Following FBI investigations HCA pleaded guilty to fourteen felonies, including systematically overcharging the government, filing false statements, fraudulently billing Medicare and providing kickbacks to doctors who referred patients to HCA facilities. The company ended up paying the federal government $631 million, plus interest, in addition to $250 million in restitution on fraudulent Medicare claims. The insurance fraud also cost HCA more than $2 billion to settle civil claims.

A key tool in combating false statement insurance fraud is for workers’ compensation patients to seek out highly reputable providers. The best approach to navigating the fray of health insurance or workers’ compensation red tape is to play it straight down the line, provide the highest level of patient care, while strictly adhering to ethical guidelines for workers’ compensation cases.

Dr. Alexander Zaks Georgetown Graduate

Dr. Alexander Zaks Georgetown Graduate: Georgetown University School of Medicine has many successful alumni. A fine example of the medical school’s alumni is Dr. Alexander Zaks. ...

Scif Fraud NOT True!

People are probably familiar with the idea of insurance fraud.  The media regularly covers stories about individuals who claim a workman's comp back injury and are then caught, via surveillance footage, as they happily jump on a trampoline with their kids.  But what about when the fraud works the other way around. 
 

What about all of the legitimate SCIF (State Comp Insurance Fund) cases that insurance companies refuse to pay for?  That is the true travesty. Medical insurance investigation SCIF Fraud CA cases are more common than one might think.

One example of medical insurance investigation SCIF Fraud CA involves two honest medical partners who have done their job, and are NOT getting paid.  It's a common practice of the SCIF to string doctors out in payment until, after a long period of time (often 4 - 7 years) the doctors cave and accept pennies on the dollar in return for their work. 

In some Medical Insurance Investigation SCIF Fraud CA cases, clinics like the ones run by Doctors only receive 30% of their original bill amount.

Medical Insurance Investigation SCIF Fraud CA -  Fraud is False!

What many people don't realize is that medical insurance investigation SCIF fraud CA isn't always based on the people who are milking the system.  A good deal of the time, it is the system who is milking the people.  How do they do this?

Medical Insurance Investigation SCIF Fraud CA - How does it happen?
 

1.      Doctors submit legitimate claims to the SCIF.

2.      SCIF doesn't pay.

3.      After a period of bill haggling, the insurance company will begin to offer less money for services rendered.
 

Medical facilities have a choice:

§  Agree to the insurance companies low-ball offers and receive as little as 30% of their original bill

§  Fight the insurance company and hold out for the full amount, putting themselves at great professional risk

4.      What medical insurance investigations SCIF fraud CA are beginning to demonstrate is that when insurance companies are stood up to, they get nasty!

5.      Insurance companies pay millions of dollars in legal fees to keep their lawyers in the courtroom fighting against honest medical practitioners, in the effort that the doctors will run out of money, or energy, and cave.

6.      When that doesn't happen, they spend more money using slander and dishonest headlines to discredit ethical medical practitioners to either put them out of business, or get them to back down.
 

A medical insurance investigation SCIF Fraud CA is in action right now as Medical Clinics are experiencing the backlash from the greedy and bullying insurance company.  Now the innocent subject of various SCIF blogs and web advertisements used by SCIF to get them to back down. It's important that this corrupt medical insurance investigation SCIF fraud CA is exposed.

Citizens Beware of Medical Insurance Investigation SCIF Fraud CA

The public needs to know that medical insurance investigation SCIF fraud CA is real and that SCIF is the true bad guy.  Anyone who has filed a workman's comp claim should document all communications with SCIF regarding their claim. If there is not an end to cases involving medical insurance investigation SCIF fraud CA, the public will lose their best and most talented doctors.

Stand up to medical insurance investigation SCIF Fraud CA.  Support legitimate doctors and write letters to politicians expressing your intolerance of situations like medical insurance investigation SCIF fraud CA.