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Strains, sprains and pains

What do you think would happen if you gave a bunch of “complementary and alternative medicine” practitioners access to a big pot of money — say, up to $10,000 per patient — and let them treat patients virtually without restriction, hampered only by a fee schedule. No utilization review, no refusal based on a treatment’s being “experimental” — none of the usual foils which trip up CAM practitioners in the health insurance field.

Think they’d run up the bill? Yes, they would.

In fact, that’s exactly the scenario playing out in Florida right now with the state’s no-fault auto insurance.

Good intentions, and the road from there

Some background: The Florida legislature mandated no-fault motor vehicle insurance coverage personal injury protection (or “PIP” coverage, as it is commonly called) for all vehicles in 1971. The laudable goal was to give those injured in auto accidents ready access to money for economic losses, such as medical bills and lost wages, without having to determine who was at fault, a process litigation could delay for several years. Up to $10,000 in coverage is currently required for all vehicles.

For medical bills, this coverage is meant mainly for temporary, and therefore generally minor, injuries. Bodily injury coverage – and the necessity for proving fault – takes over for more permanent injuries. Indeed, for 2007, according to a recent report by the Insurance Research Council (IRC), 70% of injuries reported by no-fault auto insurance claimants were sprains and strains.

By statute, only medical doctors, osteopaths, dentists and chiropractors can supervise, order or prescribe medical services for PIP claims. However, physical therapy, massage and acupuncture can be prescribed by the provider.

Medical costs represent 90% of all claimed economic losses, according to an analysis of 2007 Florida PIP claims, even though coverage is meant for other expenses due to injury as well, such as lost wages. In fact, medical expenses eat up so much of the $10,000 limit that there is often little – or no – money left for lost wages.

Since 1971, vehicle and highway safety have improved dramatically, reducing the severity of crashes and resulting injuries. According to the Florida Highway Patrol, between 2006 and 2010 alone there were 21,000 fewer traffic accidents and only a 1.5 percent increase in the number of drivers.

So, over time, there’s a trend toward fewer, less serious, accidents. As well, the injuries covered by PIP are mainly minor and self-limiting. But in Florida PIP coverage rates are out of control. According to a report issued by Florida’s Chief Financial Officer (CFO) Jeff Atwater the state’s paid PIP losses per auto have increased over 66 % in the last 2.5 years, and PIP premiums will double every 3 years if the trend continues.

Faced with these stats, the CFO (whose office regulates insurance) decided to look into things and gave the Office of Insurance Consumer Advocate the task of doing so. The Consumer Advocate’s report, issued this month, produced some very interesting data on the question I posed in the first paragraph.

And the results are . . .

The Consumer Advocate found that, for 2010, the most expensive average provider charge per PIP claim was paid to these top three providers:

  • Massage Therapist: $4,350
  • Acupuncture: $3,674
  • Chiropractor: $3,482

In contrast, the three provider types with the lowest charge per claimant were:

  • Emergency Medicine: $1,613
  • General Practice: $1,826
  • Orthopedic Surgery: $2,810

Yes, you read that right. Over 4,000 bucks for massage therapy but only about $1,600 for the ER doc.

Remember that a full 70% of these claims were – if the 2007 stats held true for 2010 — for strains and sprains. And let me go out on a limb here and guess that the emergency medicine doctors and orthopedic surgeons were treating the more serious types of injuries. Yet, they still came out far below the average per claim charges for massage therapists, acupuncturists and chiropractors.

And there are other interesting stats in the report.

Forty-three percent of Florida PIP claimants saw a chiropractor in 2007, compared to 25% seeing a General Practitioner and 9% seeing a Physical Therapist. According to an IRC report referenced by the Consumer Advocate:

Chiropractors are the largest percentage of medical providers submitting charges for treating PIP claimants and had the highest average total charge per claimant as compared with other medical providers.

Although, as we can see from the data for 2010, even they have been surpassed in average charge per claimant by massage therapists and acupuncturists.

As well, the IRC report noted:

Treatment by a GP tends to involve many fewer visits than treatment by other types of providers. For PIP claims countrywide closed in 2007, claimants treated by GPs had 4.8 GP visits, on average. In contrast, PIP claimants treated by a chiropractor had 21.7 chiropractor visits, on average.

That’s right, rounded off, 5 visits versus 22 visits, over four times as many. Think of the poor patient: maybe 22 times getting off work or getting a baby sitter. The carbon footprint alone for 22 visits is alarming. And all this for a strain or sprain?

But is it worth it?

All of this raises an obvious question: Even if treatments by massage therapists, acupuncturists and chiropractors are more expensive, are they worth it?

First, let’s examine that $4,000+ worth of massage therapy. Under state law, “massage” means

the manipulation of the soft tissues of the human body with the hand, foot, arm, or elbow, whether or not such manipulation is aided by hydrotherapy, including colonic irrigation, or thermal therapy; any electrical or mechanical device; or the application to the human body of a chemical or herbal preparation.

(I know, I know, colonic irrigation.)

While the use of “any electrical or mechanical device” might seem scarily broad and open to abuse in pumping up the bill, it appears that the massage therapists billing for treatment of PIP claimants were actually performing, well, massage. In 2010, massage and deep tissue massage were among the top ten billed procedures in PIP claims. Measured in 15 minute increments, called “units,” there were a whopping 1,836,308 units of deep tissue massage billed, and an even more whopping 4,051,016 units of what is generically referred to as “massage” billed. That’s almost 6 million units total, which equals one 15 minute massage for about every third person in the whole state of Florida. (1)

I’m no biostatistician, but I did look on PubMed to see what the evidence might be for massage. One Cochrane Review found that “massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education.” In the cited studies, massage (of several different types), lasted between 10 minutes and one hour, for between one and 10 sessions.

However, a 2007 Cochrane Review found “No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.” I couldn’t find any good evidence on cost-effectiveness compared with other treatments.

Thus, my lightly evidence-based conclusion is that, while massage might be beneficial for some types of low back pain (if this is the problem presented by the sprain or strain at hand), at $4,350 a pop it doesn’t appear that you’re getting your money’s worth.

Massage is often included as CAM by CAM proponents. I am not so sure that is a correct characterization. But for the purposes of this post, I’ll cede the point because it illustrates something proponents don’t particularly like to acknowledge: that what they call “CAM” can have some very real adverse effects on the public, even if they are not of the physical sort, a point I’ll return to later.

Let’s move on to the far more studied acupuncture and chiropractic, which won second and third place, respectively, in the category we’ll call “Most Expensive Provider of Treatment for Mostly Inconsequential Injuries.”

Sorting out the details on acupuncture is complicated by the broad scope of practice given acupuncturists under Florida law:

Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi Gong, oriental massage, herbal therapy, dietary guidelines, and other adjunctive therapies, as defined by board rule.

“As defined by board rule” is a boon to acupuncturists, because the acupuncture board has helped itself to a whole bunch of nonsense, including cupping, “thermal methods,” magnets, reflexology, laser biostimulation (whatever that is), recommendation of supplements and homeopathic preparations (which acupuncturists can also sell to the patient) and herbology.

Thus, we cannot know from the Consumer Advocate’s report how much of a billed procedure was acupuncture or “thermal methods” or cupping. But from the fact that, as the law now stands, acupuncture would have to be prescribed by a covered provider (M.D., osteopath, chiropractor or dentist) or performed by the covered provider himself, I think we can safely assume that most of what was done was acupuncture, although we don’t know what kind.

Acupuncture of all stripes has been the subject of numerous posts here at SBM, and we know that it doesn’t work for anythingPeriod. This was recently confirmed by yet another study. Thus the $3,674 per claim paid to acupuncturists is a huge waste of money.

The problem will get worse if a bill proposed for the 2012 legislative session becomes law. It would amend the no-fault auto insurance statute to include licensed acupuncturists as covered providers. This would mean that the acupuncturist is in total control of the diagnosis and treatment, no referral required. Magnets, anyone?

And finally, bringing up the rear of the top three, is chiropractic. In Florida, we adhere to the traditional, D. D. Palmer definition of chiropractic:

the science, philosophy, and art of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education.

As we know, the vertebral subluxation doesn’t exist. But tell that to the Florida Legislature.

Given the ubiquity of chiropractic belief in the subluxation, and the fact that, according to chiropractors, these putative subluxations can be caused by accidents, it seems reasonable to conclude that at least some of the $3,482 per PIP claim charged by chiropractors is going to the detection and correction of the non-existent subluxation (or one of its many iterations, such as manipulable lesion or joint dysfunction) which is, after all, the very definition of chiropractic practice in Florida.

But even when chiropractors branch out and include other treatments, the results are unimpressive. A recent Cochrane Review looked at, for low back pain, “a combination of therapies such as SMT or adjustment, massage, thermotherapies, electrotherapies, the use of mechanical devices, exercise programs, nutritional advice, orthotics, lifestyle modification, and patient education” rendered by chiropractors. (2) The conclusion:

Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.

It is interesting to note that several of the therapies employed by chiropractors and included in the Cochrane Review are among the top ten PIP procedures billed for 2010. In addition to “Chiropractic Manipulation, 3-4 regions,” which came in number 10, at 1,023,671 procedures, we have the following, along with the number of these procedures performed last year on PIP claimants by all providers:

  •  Electrical Stimulation (15 min.): 1,172,400
  •  Electrical Stimulation (time not specified): 2,219,955
  •  Hot Pack/Cold Pack: 2,315,997
  •  Ultrasound Modality (15 min.): 2,324,928

 What’s the harm?

The harm caused by CAM providers and their therapies is generally reported in terms of side effects of those therapies. Here, we have evidence of a larger economic harm to the general public. Three CAM providers – as defined by CAM proponents – are the most expensive providers of PIP-insured claims. Of these, the main therapy of two – acupuncture and chiropractic – are scientifically implausible and have (as one might guess) no evidence of effectiveness. The third, massage, is the most expensive, with limited evidence of effectiveness and no evidence that it is more cost effective than other treatments.

And all this for mostly sprains and strains.

Obviously, there are other drivers of these huge premium increases in the PIP system. One is out and out fraud. Another is increased litigation, and here it is fair to note that claimants under chiropractic care were more likely to have an attorney. For 2007, the association between the type of provider and having an attorney were:

  • Chiropractor: 62%
  •  Orthopedist: 24%
  • Physical Therapist: 15%

And here’s the harm.

According to the Consumer Advocate’s report, some Florida families are paying $3,500 annually in PIP premiums for $10,000 in PIP coverage. That’s right: more than a third of the total coverage amount in premiums.

Another example from the report: A retired couple in Tampa with one car insured by State Farm paid $471 in PIP premiums this year. The average family with teen drivers and two cars in Tampa paid almost $2,000 to State Farm for the same coverage. If this family earned the $40,000 median income for Hillsborough County (Tampa), they would be paying an astounding five percent of that income for $10,000 in PIP coverage.

We don’t know from the Consumer Advocate’s report how much of this can be attributed to diagnosis and treatment of conditions that don’t exist by covered providers. Nor can we know how much can be attributed to expensive treatment by massage therapists where less expensive but equally effective treatment might take its place.But we do know this. When given the opportunity to treat mostly minor, self-limiting injuries with methods of dubious, or no, effectiveness, and given expansive insurance coverage, CAM providers come out on top in terms of expense. And I’ll bet that’s a statistic you’ll never see CAM proponents quote.

 

Notes

1. According to the 2000 census, the population of Florida is 15,982,378.

2. To the uninitiated, the referenced “adjustment” means, in chiropractic lingo, adjustment of the aforementioned vertebral subluxation which, as noted, can’t do the patient any good because these subluxations don’t exist.

 

Posted in: Acupuncture, Chiropractic, Legal, Politics and Regulation

Leave a Comment (111) ↓

111 thoughts on “Strains, sprains and pains

  1. marcus welby says:

    This is important information. As a medical practitioner in Florida, I hate to see an auto accident patient on the schedule. I limit my exposure to one such patient a week for my own sanity, but feel some interest in monitoring the status of the personal injury sphere by still keeping my finger on the pulse of what is occurring. My observations are that most of these sprain and strain musculoskeletal pain patients seem to act as though they have won the lottery. They usually have an attorney by the time they get to my office, and often have begun a large series of chiropractic treatments with associated modalities in that office, like massage and electrical stimulation, etc. Since exceeding the 10,000 dollar threshold allows a lawsuit for big damages within the tort system, there seems an effort on behalf of the patient, chiropractor, and attorney to get past that threshold. The patient seems to get that permanent injury is more lucrative in settlements than temporary symptoms, and the distinct impression in most cases is that the patient is clinging tenaciously to their pain and refuses to let it go. Herein lies a fertile bed for 10,000 dollars of placebo treatments and a subsequent personal injury lawsuit. Some patients describe being referred to a high profile personal injury attorney by the towing service which hauled off their car, then the attorney refers them to one of several chiropractors who seem to work with the PI attorneys.
    After the 10,000 dollar PIP threshold is exceeded, the chiropractor seems often willing to opine serious permanent injury in legal proceedings, often bolstered by MRI studies, which are usually abnormal in some aspect, since a normal MRI of the spine or shoulder is unusual in most adults, and the persistence of subjective pain along with abnormal imaging is cited as evidence that permanent injury occurred due to the accident in question.
    Recognize that this sad scenario not only wastes valuable societal resources, it can ruin lives. Unnecessary surgical interventions aimed at eliminating pain may maim, and following the lawsuit over auto accident injury, subsequent depression, SSDI application, and a lifetime of disability can ensue. A claimant in an accident case often feels challenged within our legal system and by family, coworkers, neighbors over their seeming lack of injury. The claimant who feels vested in a quest for large monetary settlement for permanent injury often reacts to challenge by escalating symptoms and catastrophizing, as a strategy to silence doubters. Some get locked into a lifetime of disability, depression, self-doubt, guilt, substance abuse. What an awful system. A huge NOCEBO.

  2. marcus welby says:

    Regarding the PIP fraud outlined above, most of the accupuncture and massage being billed is by employees of chiropractic PIP clinics although there are some MDs and DOs of course, who are also preying on this pot of money: orthopedists, neurologists, neurosurgeons, PM&R (Physical Medicine and Rehabilitation) types. Pain clinics are connected as well, as pain cannot be objectively measured and the auto accident victim envisioning a large settlement for pain and suffering has a boatload of pain to treat. In Florida, it would seem that litigants in personal injury lawsuits, the majority being PIP covered, are a major source of chiropractic income. Linkages between chiropractors and personal injury attorneys seem common.

  3. ConspicuousCarl says:

    Some rough guesstimating here…

    PIP insurance in Florida costs about $600 annually if you have a good record.

    43% of claimants went to chiropractors, which can cost anywhere from 1-2.5 times as much as real medical care. An unspecified smaller fraction did acupuncture or massage (both also at higher costs than real medical care). (i.e., 50 real treatments at $1 each, vs 50 crap treatments at $2 each, = $100 spent on crap out of $150 total)

    With a rough guess, it is quite possible that about 2/3 of all PIP claim money goes to chiropractors and other quacks. So a typical Florida driver is basically being forced to hand over $400 every year to chiropractors, acupuncturists, and massage therapists. All thanks to the government’s forcing drivers to buy this insurance for their own benefit.

    Why is this even necessary? Doesn’t normal health insurance already cover accident injury?

    $600 per year would cover about a third of an individual health plan. I don’t know what percent of people in Florida lack normal health insurance, but if it is anywhere near the nationwide average of about 15% (less than half of a third), the amount of money being wasted of BS PIP coverage could easily be spent giving free full health insurance to that 15% and probably even save some money.

  4. marcus welby says:

    About 2 million Floridians have no health insurance. If you have health insurance, the insurer often resists getting involved with bills until all legal issues are settled, which may take years. Treatment becomes problematic for the injured. The PIP insurance was designed to simplify and reduce expense by avoiding fault-based litigation for smaller claims but seems to work in reverse by encouraging self-limited sprains to become major medical (CAM) and litigation problems.

  5. chaos4zap says:

    I would be very interested in knowing how the cost of these “interventions” during PIP claims compare to their equivalent when no PIP claim is involved. Surely, the average Joe that comes in from the street wanting a massage, or even a few massages, is not being charged $4,000. I’m not savy with the law, but would it be considered some kind of fraud if it could be demonstrated that there was an intentional overinflation of charges for the same product, only when it involved insurance claims?

  6. marcus welby says:

    chaos4zap: my understanding is that in Florida, the fee scale is not as much of a problem as the intensity and frequency of service. Five days a week in many cases, with massage, electrical nonsense, accupuncture, chiropractic twisting, for a patient who is quite willing to undergo whatever, since it is all paid by insurance. And with a goal of exceeding the 10,000 dollar threshold, so litigation for permanent injuries can commence….

  7. TsuDhoNimh says:

    I had a minor car accident that resulted in a back injury that was not only lingering but spreading and getting more painful.

    I had ONE visit to an orthopedic doc who mentioned many of the things mentioned by “marcus welby” … he was concerned I was headed for a life of depression and semi-invalidism. X-ray showed no problems with the spine, exam showed really tense muscles all along one side of my spine.

    His dx was muscle spasms and he handed me off to the therapy crew. I got 4-6 weeks (I forget the duration) of real massage therapy – 3x a week for 15-20 minutes of concentrated work (deep IR, heat and knowledgeable massage on the affected area, working inward to the real source of the problem) plus the required home exercises and a very small prescription for muscle relaxant. The moment she coaxed the problem muscle to relax was absolute bliss.

    One 30-second follow-up with the doc so he could sign off the case as “fixed” and I was done. The total bill to the car insurance company for the whole thing was less than $1,000.

    I am sure that with a vulture of a personal injury lawyer, a chiroquacktor and a year of “therapy” they could have had me permanently crippled and in a lawsuit that garnered them thousands of dollars.

  8. Reductionist Nurse says:

    @marcus: Your comment instantly brought one thing to mind. Dr. Nick from the Simpsons! More specifically episode #21:
    http://en.wikipedia.org/wiki/Bart_Gets_Hit_by_a_Car

    Unfortunately I couldn’t find any videos of that, but I did find another excellent short featuring Dr. Nick that echoed many of the themes in this article, enjoy:
    http://www.youtube.com/watch?v=aqImkDgDwHU

  9. CarolM says:

    “Some get locked into a lifetime of disability, depression, self-doubt, guilt, substance abuse. What an awful system. A huge NOCEBO.”

    That could be said of many disability recipients, at least the ones I know. If you’re sick ya gotta play the part.

    Strangely enough, I know two genuinely disabled people who are working full time.

  10. elmer the fake nutritionist emailer not says:

    Unfortunately, chronic pain sufferers find themselves in constant battle with human scum who don’t consider what they are suffering a “real disability.”

  11. Vince Paul says:

    You mention that whiplash is a minor self-limiting condition. My guess that opinion comes from much of Ferrari and Russell’s work. There are criticisms to their work and their conclusions that are worth noting.

    http://www.jrheum.com/subscribers/08/12/2303.html

  12. weing says:

    Maybe the reason physicians hate to see whiplash patients are the same as mine. Anecdotal experience. The patients don’t improve until the litigation is completed. I don’t enjoy testifying. Patients with a lawyer don’t seem to improve, those without, do. Which made me suspect many moons ago. Are lawyers contributing to chronic disability in some of these patients?

  13. rokujolady says:

    I’m not really feeling sorry at all for chronic pain sufferers with lawyers. Marcus, speaking of lives ruined,let’s talk about the person found to be at fault and their family. Being sued is a nightmare I wouldn’t wish on an enemy. If you put someone else through that so you or your chiropractor can have a quick buck, guilt and self doubt are what you OUGHT to be feeling. These people aren’t the victims of bloodthirsty lawyers, they hired the lawyers.

  14. Traveler says:

    “Maybe the reason physicians hate to see whiplash patients are the same as mine. … Patients with a lawyer don’t seem to improve, those without, do.”

    Lawyers are a pain in the neck? How has this gone unnoticed for so long?

  15. lilady says:

    New York State instituted PIP or No Fault automobile insurance years ago. As “Marcus Welby” and others have stated so succinctly…the “idea” was good…but has become perverted by some claimants.

    Oftentimes, the inordinate number of visits to chiropractors and other alternative “practitioners” is driven by the desire to “break through the 10K PIP coverage limit” for the institution of a lawsuit handled by the local storefront negligence lawyer. There really is no need to go to a top tier law firm…any hack lawyer will do…they are the ones who have connections with the local “practitioners” who will provide all the services for an extended period of time to build up the medical bills to break the policy limits for PIP coverage.

    Many years ago, I worked in the claims department of a very large insurance company, where I knew all the personal injury adjusters and the personal injury defense attorneys…I even married one…45 years ago. We would all analyze the bills coming in from “insurance doctors and chiropractors”, from medical splint and orthotics suppliers as well as the bills from pharmacies for prescribed pain relievers and muscle relaxants. We also had pictures of the damages and bills for repair for the vehicles that the claimant was driving or was a passenger in. It was laughable, how high all the medical bills and the huge amount of loss of earnings (considered “special damages”) were, versus the actual cost to repair the small dings and scratched bumpers resulting from said accident. Then too, there is another way to collect damages…by the spouse of the injuried party claiming “loss of consortium”. Insurance fraud is a game the whole family can play.

    Now there are “other” reasons to claim whiplashes and contusions…a mechanism to get powerful painkillers for extended periods of time. Florida is the “pill mill” epicenter of the United States.

    Small wonder then, why automobile insurance coverage is so expensive and small wonder why short term disability payments are breaking State’s budgets, and the longer term permanent disability claimed by insurance company defrauders, threatens any attempts to balance the Federal Budget.

    BTW, if you really are injured in an automobile accident and go to an emergency room or a doctor following the injury, Medicare and private insurance DO NOT pay for any of your medical bills…you must have your care providers submit claims for reimbursement to the automobile insurance company.

  16. marcus welby says:

    Vince Paul: As I recall, the Lithuanian article on lack of chronic symptoms following whiplash-type neck injuries in their country attributed the recovery mostly to the utter lack of a personal injury lawsuit system and tort culture in that Baltic country at the time (20th Century).

  17. nwtk2007 says:

    I just thought I’d chime in a bit on this discussion regarding chiropractors:

    http://ezinearticles.com/?Chiropractic-Fraud—Perception-Vs-Reality&id=1519309

    This gives a little perspective I think.

  18. Harriet Hall says:

    nwtk2007,

    Here’s some more perspective. A study of California disciplinary statistics during 1997–2000 reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for MDs; the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20)
    http://www.jmptonline.org/article/S0161-4754(04)00131-9/abstract

  19. nwtk2007 says:

    If you could send me a copy of the paper to my email, nwtk2007@yahoo I could comment on it as I am unable to see anything other than the conclusions. For example, how is the DC “disciplined” for fraud and how was it determined that there was fraud, this being a criminal offense and thus subject to criminal prosecution.

    I also find it interesting that the MD’s are once again, as always, noted for negligence, thus the huge number of medical mistakes which, as I have always said, billing for medical mistakes is the most insidious of frauds.

    Let me know if you have that paper to forward to me and I will take a look. I’m sorry but I can’t afford to pay for every paper/article out there.

    I thought Dan’s article was a bit revealing however, didn’t you?

  20. lilady says:

    @ nwtk2007: “I thought Dan’s article was a bit revealing however, didn’t you?”

    Yes, I did think “Dan’s” article was “quite” revealing…for entirely different reasons. I am wondering why “Dan” linked to the “American Association for Justice”, which is an association for trial lawyers. The American Association for Justice ranked Allstate as the worst insurance carrier for paying claimants.

    “Dan” detailed the many lawsuits that Allstate has instituted against chiropractors for over-billing, providing unnecessary services (padding the bill) and for insurance fraud.

    I say good on Allstate and any other carriers which carefully audit payments to fraudulent practitioners…and for keeping costs of automobile insurance down for the consumer.

    BTW, I derive great pleasure when I see fraudulent claimants and practitioners on TV doing the “perp walk” into criminal court, for arraignment.

  21. Harriet Hall says:

    @nwtk2007, “If you could send me a copy of the paper to my email,”

    I don’t have access to the entire paper. It’s from one of the major chiropractic journals with the best reputation – if you don’t have access to it, it makes me wonder how much of the chiropractic literature you read and how well informed you are.

    “how is the DC “disciplined” for fraud and how was it determined that there was fraud”
    Presumably the same as how MDs are disciplined and the same way it was determined that MDs engaged in fraud. The point was to compare MDs to chiropractors, and chiropractors came off worse – and this was published in one of their own journals.

  22. nwtk2007 says:

    Yes Harriet, I don’t subscribe to that or any other journals and thus I am uninformed. Right. I see you still site references which you fully admit you haven’t read. Bias at its best.

    lilady, It might interest you to note that the insurance company and its fellows you defend and proclaim had a one trillion dollar profit last year just in auto insurance yet continue to try to raise rates and based rates on credit report ratings. They, Allstate paid out more than 25 million in fines and penalties but that’s a drop in the bucket against their profits. The fines they have levied against them are for a different kind of fraud, that of bad faith, based upon their own bias against a part of the healthcare industry, but that also includes denial of payments to MD’s and DO’s as well who are treating people injured by their “insured”s.

    I like the idea that companies like Allstate can review bills and make doctors more accountable for their services which they bill for, but open denial and the targeting of particular groups is simply absurd. Its the insurance industries goal to NOT pay claims and they will play all sorts of games to avoid it.

    The sheeple just go along and continue in their brain washed following.

    Also, in the case discussed by “Dan”, the appeals court eventually decided against Allstate. Its just a matter of time until their despicable actions begin to effect more and more of the medical community.

  23. Harriet Hall says:

    nwtk2007,
    You asked “how is the DC “disciplined” for fraud and how was it determined that there was fraud”

    I answered: “Presumably the same as how MDs are disciplined and the same way it was determined that MDs engaged in fraud. The point was to compare MDs to chiropractors, and chiropractors came off worse – and this was published in one of their own journals.”

    I agree that it is always best to read entire articles rather than relying on abstracts, but sometimes entire articles are not readily available. You are unwilling to accept the authors’ conclusions without reading the entire article. I’m willing to give the article’s chiropractic authors the benefit of the doubt and assume they did a legitimate comparison between their own and MDs. I have no reason to suspect them of anti-chiropractic bias. Do you? If they had found that chiropractors were LESS likely than MDs to be disciplined or engaged in fraud, then I would have a reason to suspect that their methods might have been somehow slanted to protect their own, and that they deserved a closer look.

  24. Earthman says:

    Corruption is an evil which we in the west usually associate with the developing world. But it is here with us alive and well, and we must deal with it lest we survive!

  25. Earthman says:

    This is one of the most important papers I have seen on SBM. It clearly identifies corruption of the system, and the terrible tie up between woo and lawyers who both have self interest as a priority, rather than patient care or basic ethical behaviour. Damn them.

  26. nwtk2007 says:

    *I’m willing to give the article’s chiropractic authors the benefit of the doubt and assume they did a legitimate comparison between their own and MDs.*

    Yes Harriet, now you’re willing if it fits you’re position. How droll.

    Happy New Year lady.

    1. Harriet Hall says:

      @nwtk 2007,
      I’m willing to give them the benefit of the doubt not because their conclusion agrees with my position, but because a study gains credibility when it disagrees with the position of the authors. We know that drug studies are more likely to be positive when carried out by the manufacturer. If a drug company studies one of its own products and gets negative results, it’s particularly impressive.

  27. jhawk says:

    @ Harriet Hall

    “the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20)”

    Could this be due to the fact that there are more chiro’s in solo private practice than MD’s and thus leading the insurance companies to claim fraud on chiro’s before MD’s due to the decreased cost of litigation of a solo chiro as opposed to a hospital?

    @nwtk2007

    I am also amazed at how many here not only cite but critique evidence based solely on reading the abstract. This is extremely pseudoscientific.

  28. lilady says:

    nmkt2007: I’d watch who you are calling sheeple my friend. How could you misinterpret anything I have stated in
    my posts?

    What experience do you have in insurance? I worked in the claims department of a large insurance carrier…I also worked as an underwriter for an international insurance company…before I earned my degree, BSc-Nursing.

    I stated succinctly that I am all for nailing crooked health care providers, crooked lawyers and phony claimants who defraud insurance companies…thus increasing the cost of automobile insurance for all drivers.

    Just what might your agenda be, nmkt2007? Are you a chiropractor, a lawyer who refers clients to the “local chiropractor…or an injured claimant? Perhaps you thought you were going to score big time for your whiplash and contusions and it all didn’t happen.

  29. nwtk2007 says:

    @ lilady

    Worked in a claims office? As an adjustor? SIU?

    Then you are well familiar with Allstate’s McKenzie protocol and their intention to pretend to have the good hands but put on the gloves, so to speak. Were you one of those who would deny payment for services based upon lack of medical necessity, and yet couldn’t define it?

    I love it when the non-medical personnel take it upon themselves to declare that services are un-necessary. The claims that essentially all injuries which don’t bleed will heal themselves without any treatment at all. Or even deny payment for a doctors exam even when the exam reveals no treatable injury.

    Absolutely the best are the “peer reviewers” who site low property damage to deny injury and thus deny payment of medical services, yet when enough of their “original” reports are seen then the repetitive language becomes clear. It appears that no matter what the property damage amount, the services provided by the doctors are not necessary. And that’s all doctors. You cut their bills by 50 to 100%, make quick settlement offers to patients of $250 or $500 and get them to sign a quick release knowing full well that it won’t cover even the most basic of medical evaluations or treatments.

    Get real lilady. Its the insurance companies who have forced doctors to change huge amounts for services. Even in major medical you force them into a corner to accept 30 or 40% of their bill thus they charge 200$ for an exam just to collect 60 or $70. The high cost of health care in directly attributable to the insurances companies.

    They are an anathema. By forcing doctors to raise their costs they make it impossible for people to get decent health care with out them.

    I could go on and on but my coffee is getting cold.

    By the way, I do have a bit of experience with insurance companies.

  30. lilady says:

    You get real…I never said I worked for Allstate…but rather a large insurance carrier and an international insurance company.

    Also understand that “sheeple” is a pejorative word for an individual who supposedly has limited intelligence and who is part of the herd…recently adopted by conspiracists of all stripes such as alternative medicine “practitioners”.

    I bet you could go on and on about insurance companies…because you have “a bit of experience”.

  31. nwtk2007 says:

    @lilady – I didn’t say you worked for Allstate. But, if I know about the McKenzie protocol then you can bet that any other adjustor working for any other insurance company would know about it. As to sheeple, it is the sheeple who go along with the “status quo” and never question it. There is no implied lack of intelligence, it is implied apathy and a lack of being willing to look close enough to get involved even at the level of caring, either way.

    @Harriet – I would agree with you on that point. As to the article, however, it is difficult to see what I would consider true conclusions without seeing the methodology. In reviewing some research in the past, I have found, all too often, that the short conclusion doesn’t match with the data and, many times, is just a stretch at the very least. I am sure you know this all too well.

    If the conclusion of fraud is nothing more than difference of opinion between practicioners, then fraud is the wrong conclusion. Some DC’s and PT’s will hold that 6 manipulations or 6 sessions of therapy are all that is needed whereas others will prescribe a bit more or a lot more. If you as an MD perform a surgery that you felt was medically necessary but most or a majority of other surgeons think it was un-necessary, is it fraud that you have committed?

    In the insurance world, if a doctor performs an MRI on a shoulder sprain, then in many cases it becomes fraud. They point out that the property damage is too low to have caused anything which might be seen on MRI. But the treating doctor has to deal with his exam findings and make his recommendations based upon that. The patient might have had a pre-existing condition or previous tear that was not a problem or had reached it’s MMI many years ago and thus the slightest action could cause a flare up, which, at least in Texas, is defined as a new injury. The doctor had the responsibility to determine the nature of the injury and can’t base their decisions and recommendations upon “standards” of property damage or impact intensity. In this paper, it would be interesting to see what the “frauds” are. The insurance industry and many doctors would say that it is fraud if I recommend an MRI in this example I have invented here, but represents a good deal of what is going on in the world of MVA’s. The use of the word “fraud” is in question and should be in question every time it raises it’s ugly head.

  32. Harriet Hall says:

    nwtk2007,

    Do you really think it is likely that chiropractors did a study accusing chiropractors of more fraud than doctors by confusing fraud with mere differences of opinion? Do you really think disciplinary actions (by other chiropractors on the chiropractic boards) were carried out without good reason?

    I think you are grasping at straws to justify a belief that chiropractors are not more likely to be disciplined or to be involved in fraud than doctors. The evidence says otherwise. You might be interested in reading this report on state licensure and disciplinary actions: http://oig.hhs.gov/oei/reports/oai-01-88-00581.pdf

    And information on disciplinary actions is readily available by state. Here’s a typical list from Nevada http://chirobd.nv.gov/DisciplinaryActions.htm

  33. nwtk2007 says:

    The answers to your two questions are possibly yes and possibly yes.

    Just looking at the disciplinary actions of the Nevada board is a good illustration of what can be misconstrued as fraud. How many of those actions were for billing for services not rendered or billing for services deemed by someone to be not medically necessary.

    On the one hand, billing for a service not provided, this is clear fraud. But billing for services you deem to be medically necessary no matter what the contrary opinions does not constitute true fraud. If it were then insurance companies would give the patients records to a bought and paid for “expert” who would then “review” the records and write a “report” saying that in his opinion, the services the doctor billed the insurance company for are not medically necessary, (Allstate has done specifically this) then sue the doctor for fraud based upon this phoney experts opinion. They get it in a court in front of a jury and one never knows what might happen. The use of treatment “guidelines” is similar attempt to do this very same thing in an indirect fashion.

    As I have said, the use of the word fraud is misleading and confusing and totally misused by many people, including chiropractors. Until I see the paper and see how these guys came to their conclusions, I’ll not take it too seriously.

    I would submit that a doctor who provides a treatment he feels is beneficial, even if not backed up by “evidence” and bills for the service, is not committing fraud either. Loos at the individual actions of the Nevada board and tell me how many fall into the true category of fraud. By the way, the disciplinary actions of each states medical boards are probably just as accessible I would imagine and would look very similar to the Nevada list you provided. Lets be clear about what it is we are talking about when we say fraud.

  34. Harriet Hall says:

    @nwtk2007,

    I read through the first few cases in Nevada and found:

    Federal felony conviction for manufacturing a controlled substance and failure to report his conviction to the board.
    Willful disobedience of the law including billing patients for services not performed.
    Inappropriate communication to a patient (not elaborated).
    Unauthorized practice in violation of the law.
    Employment of a minor.
    Employing an unlicensed practitioner.
    Admitted to a violation of NAC 634.430(1)(h)
    Involvement in the unprofessional conduct of two other practitioners.
    Hiring unlicensed massage therapists in violation of the law.
    Advertising false credentials.
    Conviction of felony income tax fraud.

    Not a single one about billing for services not thought to be medically necessary.

  35. lilady says:

    nwtk2007: “Sheeple” is a pejorative term…and I don’t like your assumption that I have a herd mentality.

    I suggest you look up “eggshell skull rule”…which is the basis of tort law; its equivalent in criminal law is “you take your victim as you find him”.

    Simply stated the “eggshell skull rule” means that if you “nudge” a severely osteoporotic person with your car and the resulting fall down injury results in a fractured femur…you are held liable for the entire amount of damages, pain and suffering and loss of consortium.

    Here’s a personal anecdote for you. My husband is on Plavix and low dose ASA since February 2011. He is S/P drug-eluting cardiac stent placement. Several months ago, he was a front seat passenger in a vehicle driven by his friend. His friend slowed down on a major highway because there was a major accident blocking two traffic lanes…the guy behind him in a huge SUV must have been distracted and plowed into the right rear of the the vehicle that my husband was a passenger in. My husband had a momentary LOC (evidence of brain concussion) and was transported via ambulance to a nearby hospital. The ER physician immediately ordered an MRI…which fortunately was negative for a brain bleed. All the costs of the ER visit are being covered by his friend’s no fault automobile insurance. BTW…my husband’s anti-coagulant medication is tricky…we are already on “Plan B” (decreasing ASA from 325 mg/daily to 81 mg/daily) and he has had two serious nose hemorrhages and cauterizations. There is no “Plan C”.

    Think about your use of the “Sheeple” word, when you post here. Anything you state after that word loses its value, IMO.

  36. nwtk2007 says:

    @Harriet – You made my point Harriet. We are talking about “fraud” yes? But my answer to your second question should have been no. They were legitimate reasons for disciplinary action, yes. But the article you mentioned was regarding fraud, yes? I miss read your second question though.

    The article by Dan that I sited was about the prevalence of fraud amongst the different healthcare disciplines.

    @lilady – You have also made my point. Its a bit of an extreme example but it works. Imagine if your husband had a HNP from previous “what ever”. He goes to a chiro who examines him and determines he needs an MRI to assess the disc. The insurance co is very likely to deny payment for the MRI, send it to a peer review “expert” who would then make the claim that it was not necessary based upon the lack of property damage or that it was done too soon. Enough of these cases and then Allstate or some other insurance co decides to sue the doc for fraud based upon their medical “experts” opinion that it, the MRI and treatment was “un-necessary”. The insurance co’s deny the “eggshell skull” rule of law and imply that a doctor treating such a case is a fraud.

    As to my sheeple comment, well, I don’t think you are listening.

    The article I sited said that “fraud” was not more prevalent in DC’s than any other health care provider entity but that insurance co’s have targeted chiros. That’s all my perspective was to point out.

    Also, implying that ins rates are excessively high due to chiro’s and not other docs treating these types of injuries is bogus.

  37. weing says:

    “Also, implying that ins rates are excessively high due to chiro’s and not other docs treating these types of injuries is bogus.”

    Well, chiros, acupuncturists, and massage therapists.

    Are you saying the Consumer Advocate’s report is bogus?

  38. lilady says:

    @ nwtk2007: My husband has had previous orthopedic problems and his orthopedist has done X-rays and referred him to a PT for therapy…he has never had an MRI. My husband prefers to go to a medical specialist, not a chiropractor.

    My education is science-based. Accordingly, our “doctor” of choice is an orthopedist and our “therapist” of choice is a physical therapist.

    I suggest you view my posting on the following SBM blog, “Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic” Published by Sam Homola under Chiropractic, to see what my opinions are about chiropractic care and why I have those opinions.

  39. Harriet Hall says:

    @nwtik2007,
    “the article you mentioned was regarding fraud, yes”

    No, it was about disciplinary actions in general. Disciplinary actions due to fraud were part of the analysis.

    The Dan article says “There is no single discipline that can lay claim to a proportionately higher rate of fraudulent conduct than any other health care discipline.” But it doesn’t support that statement with any evidence. I cited an actual study indicating that it is not true. I’m sorry I don’t have access to the full text, but the authors of the Wikipedia article did, and they say it “reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for MDs; the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20). And even if insurance companies were deliberately targeting chiropractors, that would not speak to the actual incidence of fraud, nor should it result in disciplinary actions by the boards.

    I will continue to accept their findings that both fraud and disciplinary actions occur at a proportionally higher rate among chiropractors than among physicians unless you can demonstrate the opposite with actual evidence. And you have not even attempted to support your claim that fraud convictions are due to simple differences of opinion about what treatments are necessary.

  40. nwtk2007 says:

    Until I can read the paper and see what it is they are referring to as fraud I’ll withhold further comment regarding it.

    Quite frankly, I am a bit surprised that the other anti-chiro folk here haven’t jumped in with all the evidence taht I would assume to be out there to should how much more fraudulent the chiros are than the MD’s.

    I am short on thime but here are a few links you might want to scan a bit to see how many instances of the fraud indicated are chiropractic in nature.

    http://www.irs.gov/compliance/enforcement/article/0,,id=246535,00.html

    http://www.irs.gov/compliance/enforcement/article/0,,id=228090,00.html

    http://www.irs.gov/compliance/enforcement/article/0,,id=213773,00.html

  41. nwtk2007 says:

    Additionally, if you will review Dan’s paper, the case of Allstate versus Accounts Receivable was a prime example of alleged fraud being one doctors opinion (Allstate’s expert) against the opinion of some treating doctors. The jury found the doctors liable for conspiracy to commit fraud but on appeal the jury verdict was overturned.

    In that case there was no evidence of anything being billed for that was not performed, it was simply the insurance company claiming the treatment was not necessary.

  42. nwtk2007 says:

    Until I can read the paper and then see what it is they are referring to as fraud I’ll withhold further comment regarding it.

    Quite frankly, I am a bit surprised that the other anti-chiro folk here haven’t jumped in with all the evidence taht I would assume to be out there to should how much more fraudulent the chiros are than the MD’s.

    I am short on thime but here are a few links you might want to scan a bit to see how many instances of the fraud indicated are chiropractic in nature.

    http://www.irs.gov/compliance/enforcement/article/0,,id=246535,00.html

    http://www.irs.gov/compliance/enforcement/article/0,,id=228090,00.html

    http://www.irs.gov/compliance/enforcement/article/0,,id=213773,00.html

  43. nwtk2007 says:

    @weing – actually I would not deny the validity of the report. What I would point out is that the $1600 or so for the ER doc probably amounts to billing for all of 15 or 20 min of doctor/patient interactions, if that.

    I see hospital records and bills almost daily. The patient is seen for a brief moment by the doc, given a script, maybe x-rayed, occ CT’ed and the patient later gets an itemized bill indicating the ER doc billed 400 to $600 for the “eval” and the hospital tacks on an additional $400 or so, service unknown. Add in the bill from the radiologist, the bill for the X-rays/CT if done, etc, etc, then the patient has a $3000 to $4000 bill for very little in terms of care and attention, other than long waits to be seen, long waits to be allowed to leave, etc, etc.

    In my own experience, my daughter was seen for about 5 min by an ER doc, this after sitting for two hours to be seen, he looked at the xrays (actually called the radius the ulna, and visa versa), determined that there was no fracture, and sent us home. The bill was an astounding $1200.

    I would say that the amazement that the other providers bills are so much higher is a bit disingenuous. Of course once the ER doc determines that the patient isn’t going to die or need to be admitted for further hospital care, his job is done. But it does seem a bit high for the actual time involved with the patient.

  44. Harriet Hall says:

    @nwtk2007,

    “the case of Allstate versus Accounts Receivable was a prime example of alleged fraud being one doctors opinion (Allstate’s expert) against the opinion of some treating doctors.”

    Is that all you can come up with? One judgment of fraud (overturned, at that!) says nothing whatsoever about whether a higher percentage of chiropractors than MDs commit fraud or are disciplined. And it says nothing about whether insurance companies are singling out chiropractors for persecution.

  45. nwtk2007 says:

    Interesting that you don’t see the significance of that case.

    And yes, it was over turned. At least an example of one less fraud conviction against chiro’s.

    I posted twice three links to IRS investigations of healthcare related fraud but the system says both comments are waiting to be moderated.

    But really Harriet, if it were the case, that DC’s commit more fraud that MD’s, there would be much more for you and the anti-chiro’s here to post. I think they would have chimed in quite nicely to aid in your position.

    Anyway, maybe the moderators (you?) will allow my comment to be posted.

  46. lilady says:

    Well nwtk2007 provides us with an anecdotal story of a visit to an E.R. with his daughter, where he claims that the ER physician misidentified bones in the arm.

    He also states that he and his daughter had to wait two hours to be seen in the E.R., probably because her possible injury was not life-threatening and she was “triaged” while ER staff were attending to real life-threatening injuries or medical conditions.

    He complains about the high cost of an ER visit for a “relatively minor” injury, while extolling the virtues of chiropractors. So, why didn’t he take his child to a chiropractor for the X-ray to rule out a fracture? It just doesn’t make sense. Could nwtk2007 be part of the problem of using the ER for non-emergency situations?

    Just what are nwtk2007 “credentials”, aside from “seeing hospital records and bills almost daily” and his loyalty to chiropractors?

  47. nwtk2007 says:

    Yes lilady, I do think the ER bill was excessive, probably because the ins company has already locked him and the hospital into accepting %40 of their bill or possibly less, thus they raise the fees to compensate. Unfortunately, they cannot offer two fee schedules and thus a person who is paying out of pocket will have to pay the full amount while the insurance company will only have to pay the reduced amount for his services. Of course I had to meet the deductible.

    And of course she was “triaged” and had to wait for other more serious conditions to be seen.

    As to taking her there as opposed to a chiro, well, anyone who knows anything about chiropractic knows that the treatment of fractures is outside the scope of practice for chiro’s. Also, in this case, my daughter was with her mother who took her to her pediatrician first but they told her to go to ER since it was already 430 on a Friday and they were about to close, which I understand totally.

    As to the ER doc misreading the x-rays, well, even my wife saw the mistake and simply motioned for me not to say anything as we could both see there was no fracture. Of course I could have x-rayed it myself but they were a long drive away and it was the rush hour, plus, if I had and there was a fracture we would have been in the same boat.

    As to me being the “problem” with non-emergency cases going to the ER, you would have to address that with the MD/pediatrician, who sent them to the ER in the first place. Also, it is my understanding that if the triage determines that a condition is not an emergency then it can be referred to an outside clinic for more appropriate treatment.

    Really lilady, I certainly don’t have any “loyalty” to chiro’s, but when I hear the pot call the kettle black, well.

  48. IgorK says:

    @lillady: YO\ou beat me to the punch regarding NYS no fault coverage. I previously held associate positions in both plaintiff and defense personal injury firms. Acupuncture and chiropractic treatments were often prescribed to no-fault (or workers’ compensation) patients by a medical doctors in charge of a physical therapy clinic and often take place at these clinics in conjunction with legitimate PT. It’s unfortunate, but to a great extent, greedy medical professionals who maintain a practice exclusively devoted to treating personal injury victims are to blame for wide use of acupuncture. Ironically, no fault legislation which was enacted to prevent insurance fraud resulted in equally damaging and pervasive problem of medical insurance fraud. Insurance companies, weary of billing fraud, frequently resort to sworn examinations to confirm medical treatment. Unfortunately, acupuncture in and of itself is a covered treatment as long performed “properly.”

    I always hated the idea that doctors affiliated with personal injury litigation vary their medical opinion depending on the side to which they report. However, I was limited in my criticisms due to the circumstances of my professions. Thankfully, I switched fields less reliant on medical quackery or lax medical practices.

  49. Harriet Hall says:

    @nwtk2007,
    “Interesting that you don’t see the significance of that case.”
    Interesting that you don’t see that one anecdote about chiropractors doesn’t make your case about chiropractors compared to MDs.

    “if it were the case, that DC’s commit more fraud that MD’s, there would be much more for you and the anti-chiro’s here to post.”
    If it were the case that DC’s don’t commit more fraud than MD’s, there would be much more for you and the pro-chiro’s to post.

    There is no post by you awaiting moderation.

  50. IgorK says:

    Of course the question of who commits more fraud here is somewhat academic. After all, if all evidence is against effectiveness of an alt med practice, aren’t all treatments by practitioners willfully disregarding such evidence fraudulent in nature? I don’t think there is much need to dispute who commits more fraud among M.D. or faith healers?

  51. nwtk2007 says:

    I just posted the comment and links for the third time Harriet and it once again says my comment is awaiting moderation. I’ll just put the links in separately. This might be causing a glitch.

  52. nwtk2007 says:

    Until I can read the paper and see what it is the DC’s are referring to as fraud I’ll withhold further comment regarding it.

    Quite frankly, I am a bit surprised that the other anti-chiro folk here haven’t jumped in with all the evidence that I would assume to be out there to should how much more fraudulent the chiros are than the MD’s.

    As I am not a faith healer then I can certainly agree with IgorK.

  53. Harriet Hall says:

    @nwtk2007,

    Your links are to lists of examples of fraud, not to any statistics comparing chiropractors to MDs or showing that differences of opinion lead to unfair accusations of fraud directed more at chiropractors than at others. In fact, they are only examples of IRS fraud, not health fraud. What point are you trying to make?

  54. nwtk2007 says:

    http://www.stopmedicarefraud.gov/HEATnews/texas.html

    The internet is rampant with instances of health care fraud convictions.

  55. nwtk2007 says:

    http://www.stopmedicarefraud.gov/HEATnews/texas.html

    I guess these could fall into the category of fraud depending upon who was being billed for the drugs. At any rate, bad.

  56. nwtk2007 says:

    Here’s a few from BCBS. At least one chiro there.

    http://www.bcbsm.com/home/health_care_fraud/fraud_files.shtml

  57. IgorK says:

    @NWtK: Also keep in mind that as of 2008, according to AMA, there were approximately 954,000 physicians in the U.S. compared with 49,100 chiropractors. Any fraud analysis must take this proportion into account. Moreover, your sources on medical fraud include nurse practitioners as well, which increases the number of individuals drastically.

    Of note, I think incidences of fraud by chiropractors, with few notable exceptions, will be lowered as the result of general lack of private insurance coverage for chiropractic services in the U.S. Even medicare, Manual manipulation for subluxation of the spine is the only chiropractic service that is covered by Medicare only pays for manual manipulation for subluxation of the spine, Private individuals are less likely to report fraud, whereas insurance companies frequently conduct sworn examinations of patients to detect fraudulent conduct. They are also more likely to hire professionals with the specific purpose of detecting fraud and to pursue legal actions. Of course, this is just my opinion based on professional experience, but I’m sure this can be verified by checking the incidence of fraud claims by insurance companies vs. those made by private individuals paying out of pocket.

  58. nwtk2007 says:

    Actually they are links to lists of health care fraud convictions and investigations. You had cited an article which implied that chiro’s were more prolific fraud violators. One would think that there would at least be close to an even number of chiro’s versus medical professionals in those lists of convictions and investigations.

    I guess I missed the point of your perspective which was in response to mine which was to show that chiro’s do not commit more fraud than other health care professionals.

    At any rate, it would appear that the paper you sited might be in error as to the instances of health care fraud for the DC’s reported in the article.

    You had stated that according to that paper, “”the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs”". Of course they were looking at doctors disciplined by their licensing boards if I remember correctly. Perhaps the medical boards, those that license MD’s tend to look the other way when fraud by MD’s rears its ugly head, else they might have a few more in their lists of those disciplined by them.

  59. nwtk2007 says:

    Igork, the difference between private individuals and insurance companies is that the private individual for one, knows for sure whether or not the service was performed, thus they are unlikely to have paid for it and thus be defrauded. Second, they are generally not in the habit of hiring other doctors to write reports saying that a particular treatment or amount of treatment is un-necessary so as to avoid payment with the implies accusation of fraud. If they feel that way, they simply stop going, which I guess anyone could do at anytime if they felt like a treatment was doing them no good.

    I could agree with you on the sheer number of MD’s versus the number of chiro’s. And if we take that into account, making adjustments for that, we might actually find that the amount of fraud committed by chiros is about equal to that of medical professionals. Maybe. Certainly not 9 times greater among chiro’s than among MD’s.

  60. Harriet Hall says:

    @nwtk2007,
    You think the paper I cited was in error, but you haven’t provided any evidence to show that it is – only your biased speculations.

  61. Harriet Hall says:

    As IgorK points out, many of the treatments chiropractors do could be classified as fraud – but only if they were intentionally deceiving patients. I think that is rare; I think it’s far more common for them to be deceiving themselves. For example, I think most of those using applied kinesiology have convinced themselves that it works, because of confirmation bias, positive feedback from patients, and because they don’t have the critical thinking skills to realize what is going on.

  62. IgorK says:

    “Igork, the difference between private individuals and insurance companies is that the private individual for one, knows for sure whether or not the service was performed.”

    Not always, especially when patients are not familiar with billing practices and treatments particular to the respective field. Healthcare fraud can take various forms not limited to billing for fake services. In fact, i can guarantee you based on experience, that although patients were generally able to describe a particular chiropractic treatment, they had little knowledge of how/how many times it was billed, or whether the procedure was even necessary. At any rate, in the event of being billed for unperformed procedures, individuals will generally not pursue legal action upon reimbursement by the provider. This is not the case with insurance companies or attorney general.

    “Second, they are generally not in the habit of hiring other doctors to write reports saying that a particular treatment or amount of treatment is un-necessary so as to avoid payment with the implies accusation of fraud. If they feel that way, they simply stop going, which I guess anyone could do at anytime if they felt like a treatment was doing them no good.”

    This actually supports my initial point. I am not sure what point you are trying to make here.

    “Certainly not 9 times greater among chiro’s than among MD’s.”

    Or we could find it is just that. Certainly, it would make sense that a doctor who spent 7 years and hundreds of thousands to obtain a license will take greater care then a less invested individual. Is there a disciplinary body for chiropractors and are there any disciplinary consequence for chiropractors who commit fraud?

  63. nwtk2007 says:

    Igork, you are confused. By private individual, I mean cash paying. A patient paying cash will not be paying for something not performed. I would also agree that many who use health insurance don’t understand the billing, as I can attest to looking over my own hospital bills or the papers sent to me by the insurance company showing me what it is they payed for or not. Your statement about the insurance companies and the attorney general is also true as the many medical professionals in the lists I have provided could attest to.

    Yes of course there is a disciplinary body for chiropractors. That is what the paper cited by Harriet is all about; doctors disciplined by the disciplinary body; usually the licensing board. In Texas it is the Texas Board of Chiropractic Examiners and for MD’s the Texas Medical Association I believe.

    Now as to that paper you cited Harriet, until I read it I cannot comment on it further. But I would say that given the sheer number of MD’s sited in the lists provided for fraud investigations and convictions, it would seem that the disciplinary body for the MD’s are looking the other way when these offenses are committed. The internet literature certainly does not jive with the reported conclusions, at least when one does internet searches for instances of health care fraud investigations and convictions among all providers.

  64. IgorK says:

    “Igork, you are confused. By private individual, I mean cash paying. A patient paying cash will not be paying for something not performed.”

    I fail to see where my confusion lies, especially since after stating tat you proceed to agree with me on several points. Are you sure you aren’t confused about my confusion? A cash paying patient will pay as billed (instantly or billed at a later date) without necessarily knowing if the services performed cost what patient was charged or if every procedure billed for was in fact performed. According to your logic there can never be fraud in consumer retail either because patients would not pay for the product they would not receive. It might be easier to defraud an insurance company unconditionally and without verification paying the bills, but it can be just as easy to defraud individual consumers who lack the sophistication and resources insurance companies have in abundance.

    “That is what the paper cited by Harriet is all about; doctors disciplined by the disciplinary body; usually the licensing board.”

    I missed that part and wasn’t sure about the criteria used for chiropractors. All things being equal then, since both bodies of professionals were disciplined by their respective boards, I don’t see what reason you might have for disputing the results, other then coming up with pure and unsupported speculation that fM.D. disciplinary bodies excuse fraud at a much higher rate. Note that disciplinary actions range in severity, so the board has an option of issuing same without imposing a draconian measure.

    “But I would say that given the sheer number of MD’s sited in the lists provided for fraud investigations and convictions, it would seem that the disciplinary body for the MD’s are looking the other way when these offenses are committed.”

    A quick search of fraud convictions for chiropractors reveals a similar multitude of examples. Considering that there are 20 times more doctors then chiropractors in U.S. I wonder how you can establish anything without proper data analysis? At this point the only reliable evidence was provided by Harriett. You are just guessing with a huge margin of error considering the disparity between the two groups.

    “The internet literature certainly does not jive with the reported conclusions”

    Which makes sense if you are dealing with 1 million doctors and 60 thousand chiropractors and, instead of collecting reported data like the study above, do a Google search and base your conclusions on your perception (even without confirmation biases, etc.) of numbers. This is the precise reason why one needs a study and proper data.

  65. nwtk2007 says:

    So Igork, if as you say there a million MD’s to just 60,000 DC’s, then that is approx 17 to one. With the internet obviously flooded to a much greater extent with investigations and convictions of MD’s (medical professional) for fraud, then at the very least there should be quite a few more disciplinary actions by the licensing boards of MD’s versus Chiro’s, yet the guys who wrote the paper Harriet sited are claiming a much higher rate of disciplinary actions against chiro’s by their board for fraud or fraud related offenses.

    It must be pretty clear that this is the case. There are too many anti-chiro folk here to let that lie without tallying it up and yet they haven’t.

    But what ever, sooner or later it’ll get done.

  66. nwtk2007 says:

    So Igork, if as you say there a million MDs to just 60,000 DC’s, then that is approx 17 to one. With the internet obviously flooded to a much greater extent with investigations and convictions of MD’s (medical professional) for fraud, then at the very least there should be quite a few more disciplinary actions by the licensing boards of MD’s versus Chiro’s, yet the guys who wrote the paper Harriet sited are claiming a much higher rate of disciplinary actions against chiro’s by their board for fraud or fraud related offenses.

    It must be pretty clear that this is the case. There are too many anti-chiro folk here to let that lie without tallying it up and yet they haven’t.

    But what ever, sooner or later it’ll get done.

  67. Harriet Hall says:

    @nwtk2007,
    “With the internet obviously flooded to a much greater extent with investigations and convictions of MD’s (medical professional) for fraud”

    1. That is your impression unsubstantiated by any studies or statistical analysis.
    2. There are far more MDs than DCs, so one would suspect more MD incidents even if MDs were less likely to commit fraud than DCs.
    3. You haven’t shown us any evidence that the study I cited is wrong, only your own speculations and accusations.

    You have lost this argument. You have 4 options:
    1. Get the study I cited and show us that its methods were faulty and that no conclusions can be drawn from its data.
    2. Find sufficient contradictory evidence to show that that study’s conclusions were wrong.
    3. Gracefully fade away.
    4. Continue harping on the same unfounded claims and make a fool of yourself.

  68. IgorK says:

    “With the internet obviously flooded to a much greater extent with investigations and convictions of MD’s (medical professional) for fraud, then at the very least there should be quite a few more disciplinary actions by the licensing boards of MD’s versus Chiro’s”

    Once again, internet is flooded with reports of civil and criminal fraud related charges against MDs. A google search of same for chiropraths reveealsed a similar flood. These cursory internet searches tell me nothing else as they fail to provide acurate and reliable data. Perhaps you are gifted with some amazing cognitive abilities allowing you to quickly extrapolate large numbers from a small internet search sample. I claim no such ability, so unless you can provide actual data someone gathered, preferably in California for year 1997-2000, I have no realiable way of determining whether you are right or wrong in that assumption.

    Although, for a number of reasons, a single state should not be used to extrapolate to the rest of the country, I’ll do so anyways for a general idea of total numbers. For chiropractors, the nationwide incidence of of fraud disciplinary actions is approximately 120 per year. For doctors it would be in excess of 200 per year. The numbers seem somewhat consistent with your expectations as twice as many physicians are disciplined every year, sufficient to give you the impression of large number of civil and criminal cases against them. Even then, i cannot overemphasize the point that without actual data, any conclusions are speculative. “It looks like on the Internets” is a lousy way to do research.

    “It must be pretty clear that this is the case. There are too many anti-chiro folk here to let that lie without tallying it up and yet they haven’t.”

    If you think my objection to you is anti-chiro simply because i pointed out that basing statistical conclusions on seeing many reports on the internet is simply guesswork, then you aren’t really interested in proper or accurate research, especially if it contradicts something you have a vested interest in. If you note, noone here accused you of being pro-chiropractor in lew of provided substantive arguments. You can’t be seriously suggesting that others collect the data you haven’t collected yourself, even though you already concluded it proves your point. If you are claiming something as proof you have to present it. I barely have enough time sorting through all the irrelevant information in your links. Do you seriously expect me to sift through thousands of reports on google to prove or disprove your point? Clearly you have a vested interest in demonstrating a particular point, then perhaps you can do the legwork and put up or shut up.

    Maybe you are right, even if to an extent, but at this point you are just speculating.

  69. rwk says:

    @Harriet Hall
    Having an argument and whether one uses logic correctly is all this site is about right?

  70. rwk says:

    @IgorK
    ” Do you seriously expect me to sift through thousands of reports on google to prove or disprove your point? ”
    That’s what Harriet Hall expects anyone that disagrees with her to do which is usually nwtk2007.

  71. IgorK says:

    “2. There are far more MDs than DCs, so one would suspect more MD incidents even if MDs were less likely to commit fraud than DCs.”

    Something my very rough extrapolations demonstrate is consistent with what nwtk expects to see based on the study you cited. I am neither a doctor nor a chiropractor, nor do I work in the medical profession. I have no vested interest in either side being right on this issue. Were I an MD, perhaps it might even look like the internet is “flooded to a much greater extent with investigations and convictions” of chiropractors. Instead, I can’t really tell, nor would it be proper to reach any reliable conclusion based on a cursory glance of search engine hits. If you think I am incorrect based on my unwillingness to use a few google hits as data then nwtk should tell me why he thinks his perception is more reliable then mine and how can he tell with such confidence that there is substantially more then just twice as many MDs convicted of fraud. Or he can present the actual data, even for just CA.

  72. IgorK says:

    “Having an argument and whether one uses logic correctly is all this site is about right?”

    Correct, but it doesn’t add anything to your argument. Unless youn are claiming that we are all being illogical, in which case i would gladly address any specific instances you think are flawed in logic.

    “That’s what Harriet Hall expects anyone that disagrees with her to do which is usually nwtk2007″

    Please point to where she made a claim where she required you to provide data supporting her bare claims? I might have missed it, in which case you can point it out with ease and I will apologize. So far, you were the one who made the claim about the expected numbers based on your perception of a few hits on google. Being your claim not based on any reliable data other than your perception of internet hits we pointed out that a reliable conclusion cannot be reached one way or the other. No researcher would base any published conclusion on what it looked like on the internet. However, you might be right, and have a chance to demonstrate it (especially since you are already ceretain) by presenting us with actual numbers you collected. Conversely, you can insist that it is everyone else’s job to collect the data proving your point, which is simply childish. Imagine if I told my adversary in court to look up and present all the legal precedent supporting my position after I cited none? I would get laughed out of the courtroom, in addition to loosing the argument.

  73. rwk says:

    @IgorK
    “Correct, but it doesn’t add anything to your argument”
    I’m not arguing. It’s bad enough I spend too much of my time here reading other people arguing back and forth.
    Actually it’s usually about ambushing someone like nwtk2007 who takes on pro-medicine.

    “Please point to where she made a claim where she required you to provide data supporting her bare claims?”

    How about here #1. 1 or 2 comments before yours:

    “You have lost this argument. You have 4 options:
    1. Get the study I cited and show us that its methods were faulty and that no conclusions can be drawn from its data.
    2. Find sufficient contradictory evidence to show that that study’s conclusions were wrong.
    3. Gracefully fade away.
    4. Continue harping on the same unfounded claims and make a fool of yourself.”

  74. rwk says:

    @IgorK
    I think your last comment is directed towards nwtk2007.
    rwk is not nwtk2007

  75. IgorK says:

    my bad, RWK, getting a little too late. My point stands however.

    “Actually it’s usually about ambushing someone like nwtk2007 who takes on pro-medicine.”

    I am pro whatever works. I try to be a mediator since in most instances being wrong on an issue is not a damning personal trait. I held demonstrably false views before and gracefully accepted it when evidence warranted it. I probably still do, at least to an extent. Certainly I did not enjoy proven wrong by another, but accepting one’s error when apparent and moving on, perhaps even to be correct another day, is crucial for progress as an individual and as part of society. Were i an impartial observer, even if someone was ultimately correct they would undermine their argument by acting as nwtk.

    To recap, Dr. Hall presented a study indicating higher incidence of fraud disciplinary actions among DC’s as compared to MDs in CA. The authors of the study, in the parlance of our times, “showed the work” before reaching that conclusion. They might be wrong, but if one thinks so one has to present substantive arguments pointing out why they were wrong. Researchers do it all the time as part of peer review. NTWK ended up fixating on a point that there are obviously so many MD fraud convictions that it can’t possibly be consistent with the ifraud instances cited by the study. He might be right, but in support he kept on repeating that he was certain because it looked like it after an internet search. he cited no numbers, and when it was pointed out that the subjective and unreliable nature of his approach helps neither side he accused everyone asking for poof of being anti-chiropractic and unwilling to collect the data to rpove his point. He appeared obstinate, evasive and accusatory. Rather then trying to prove his position, which may be correct for all we know, he accused everyone disagreeing with him of bias and reiterated that he was right since other’s were unwilling to collect the data he needed. I don’t know if he/she regularly resorts to such behavior. Perhaps the “ambush” got to him/her, as i am sure it can be overwhelming to have multiple individuals with detailed knowledge of the subject accost you with arguments. Unfortunately, such conduct, regarding of the issues, only further undermines ones position and credibility.

    Ultimately, i accept many things are possible, but it’s not unreasonable in our word full of charlatans and well meaning idiots to ask for a modicum of verifiable proof. I never enjoyed being right for the wrong reasons. Perhaps accidentally right is good enough for some, but luck eventually runs out, and even in high school math you loose points for not showing your work.

  76. IgorK says:

    “How about here #1. 1 or 2 comments before yours:”

    Please be a bit more specific. I don’t seen any such instance. Dr. Hall already perented a study with salient data showing a higher incidence of fraud among DCs. I’m not sure where she is asking sure where she asks for those who disagree to provide any data further supporting this claim. SInstead, it seems like the onsu is on those disagreeing with the conclusions of the study to point out where why or how it’s wrong, or to present actual data supporting NTWK’s point. If I’m wrong please point out where, it’s certainly late and I am likely to miss something.

  77. Harriet Hall says:

    This is becoming tedious. How about a moratorium until someone can come up with better evidence?

  78. nwtk2007 says:

    Igork – “To recap, Dr. Hall presented a study indicating higher incidence of fraud disciplinary actions among DC’s as compared to MDs in CA. The authors of the study, in the parlance of our times, “showed the work” before reaching that conclusion. ”

    No, what she presented was essentially an abstract of a study, something which, if it was opposed to her position in the discussion, she would never have accepted. Her reasoning that it was written by DC’s doesn’t provide adequate substance for us to accept this on its face value alone.

    I have provided links from the IRS and FBI showing both current and past investigations and convictions of fraud demonstrating how few are the instances of DC perpetrated fraud versus MD’s and the medical community in general, at least based upon actual data from two real investigative bodies which suggests (and little more) that their data might not be good. Since she did not present the entire paper we cannot know that. Igork says a similar search for chiro’s perpetrating fraud turns up a similar list, yet he provides no such links to those lists. And I would think that a list of investigations and convictions from the IRS and FBI would be a bit more acceptable than what turns up when one searches for chiro fraud; basically “hits” on a google search which amount to little more than articles from various news sources et al.

    So don’t proclaim “victory” of an argument/discussion with such little to go on; an abstract of a paper and a fictitious list of chiro fraud cases. But hey, its the internet. You can proclaim anything. And tedious it is.

  79. nwtk2007 says:

    And here’s one more list from the department of Health and Human Services. Although looking at the plethora of fraud related actions one can see the list includes many individuals who are not doctors, a brief scan showed no chiro’s on the list.

    So that’s the FBI, the IRS and the Dept of Hlth and Human Services. Pretty substantial groups when it comes to fruad related crimes. And from what I can tell, these aren’t instances of fraud based upon a difference of opinion of doctors, which I suspect some of the ones on the DC’s list might be, although I don’t know since Harriet didn’t present the entire paper for us to examine.

    Anyway, that’ll be it for a while.

  80. nwtk2007 says:

    http://oig.hhs.gov/fraud/enforcement/criminal/index.asp

    Of course this one includes a lot of non-doctor entities, but scanning it there are plenty of examples of fraud committed by MD’s. I saw no chiro’s but I’m certain there must at least be one or two. This list expands to include many, many over the past few years.

  81. Harriet Hall says:

    I didn’t claim victory because of one study. I claimed victory because I offered published evidence and my opponent responded only with uncontrolled observations, speculation, and the accusation (made only on the basis of the abstract) that the chiropractor authors of the study must not have done proper research or must have written a misleading abstract.

    Again, I call for a moratorium until someone finds actual evidence to present.

  82. IgorK says:

    “Her reasoning that it was written by DC’s doesn’t provide adequate substance for us to accept this on its face value alone.”

    Yet you simply dismissed others’ arguments for having anti chiro bias and, thereofre, lying to you? You are, however, technically correct, full paper would facilitate this discussion. In the absence thereof, however, the paper is still the most reliable evidence presented so far. If you are aware of contradicting studies or date, the onus is now on you to present it. Certainly a full text of journal published article contradicting the one cited by Ms. Hall will have greater evidentiary weight in light of Dr. Hall’s limited text. For now, unless you have some objective rationale for distrusting the conclusions of this article submitted for peer review to a Chiropractic journal with high impact value, the conclusions are valid until shown otherwise.

    “I have provided links from the IRS and FBI showing both current and past investigations and convictions of fraud demonstrating how few are the instances of DC perpetrated fraud versus MD’s”

    Then perhaps you can provide the actual numbers, because according to the conclusions of Dr. Hall’s citation we would expect at half as many fraud convictions for DC. I will do the work for you this time and address the fraud instances reported in the links your provided:

    http://www.irs.gov/compliance/enforcement/article/0,,id=246535,00.html – Not a single instance of fraud by an M.D.

    http://www.irs.gov/compliance/enforcement/article/0,,id=228090,00.html – 2 MD’s and 1 DC

    http://www.irs.gov/compliance/enforcement/article/0,,id=213773,00.html – 7 MDs (1 for alt med fraud)

    I won’t address the rest of the sources due to time limitations in sifting through duplicate case reports. It seems that you didn’t read the information you posted, otherwise why the first link? The results are too few for any statistically significant analysis especially with 2011 showing a drastically different trend from 2010 fiscal year Moreover, these are all instance of medicare/medicaid fraud which cover only one type of chiropractic treatment as indicated above. I certainly expected no chiropractors, but one chiro and one alt med doctor. I would be curious to see percentage of chiropractiv treatment covered by some form of insurance vs. private payments as compared with medical treatment under simila circumstances.

    at any rate, the IRS data shows significantly fewer convictions for either party and tells little without accounting for civil fraud judgments. When we look for instances of fraud among chiropractors outside medicare limitations:

    -http://abclocal.go.com/wabc/story?section=news/local/new_jersey&id=8274473 – 3 chiropractors prosecuted for fraud

    -February 1, 2002 – chiropractor Thomas R. Lawrence was convicted of 36 counts of mail fraud wire fraud, false claims, and money laundering.

    -February 4, 2003 3 DCs, Ron Halstead, William C. Filcheck Jr. D.C., and Scott G. Taylor , D.C. were found guilty of conspiracy to commit fraud and healthcare fraud. A fourth defendant, Robert B. Burns, Jr., D.C., who owned the clinics in which the fraud took place, has been arrested in Ireland and is fighting to prevent extradition to face the charges

    http://www.fbi.gov/newhaven/press-releases/2011/chiropractor-admits-role-in-insurance-fraud-scheme – DC guilty plea for fraud

    http://www.fbi.gov/washingtondc/press-releases/2011/maryland-chiropractor-pleads-guilty-to-insurance-fraud – DC guilty plea of conspiracy to commit wire fraud

    I can continue ad nauseum posting fraud convictions for DCs which appear plentiful once you let someone else do the cherry picking. But once again, even if i provided more incidence of fraudby DCs this way, the data, without combing through all possible sources will be unreliable and incomplete. I am merely pointing out that my searches, which provided ample hits for DCs your searches omitted, likely not intentionally, are equally worthless in reaching any reliable conclusion. The proper way would be to thoroughly examine California civil and criminal insurance fraud court records preferably for the same years as the study cited by Dr. Hall. Until then, the disciplinary board study is the only remotely reliable proof provided.

  83. nwtk2007 says:

    Ok Harriet. You offered a published abstract, nothing more. I offered published lists of actual convictions and ongoing investigations by the FBI, IRS and Dept og Human Services. Published. You can tally it up for your self.

    I would trust them for figuring out real fraud way before I would trust licensing boards of MD’s and Chiro’s.

    But that’s ok, I totally understand your position.

  84. IgorK says:

    “Again, I call for a moratorium until someone finds actual evidence to present.”

    My apologies for disregarding your first call for the moratorium. You can disregard my last post.

  85. nwtk2007 says:

    Igork, the examples you have sited span 10 years. Cherry picking? I gave links to the actual convictions and investigations of the IRS, FBI and Dept of Health for only a few years. I preselected none nor did I eliminate any.

    By the way, the three lists that you analyzed, show a ration of 9MD’s to 1 DC. And that’s just the IRS.

    Sorry Harriet, but I have given “real” evidence although woefully incomplete.

  86. Scott says:

    No placebo control = minimal credibility. Seriously, why do chiropractors even waste their time doing such shoddy research? The cynical might suspect that it’s because good research doesn’t give the results they want.

  87. nwtk2007 says:

    Interesting article rwk. There was a similar period of research in Canada in the ’80′s when they were able to demonstrate, without placebo I might add, that simple changes in life style were able to extend life as well as by-pass operations. It was a study precipitated by the apparent “wait” for the surgery and those who, after the long wait, turned out to not need the by-pass after all.
    patients who have a sprain/strain injury, just how much difference is there going to be in the treatment? When an insurance company refuses to pay for any treatment based upon their belief that there is no medical necessity for the treatment, it is tantamount to an accusation of fraud, but is not actual fraud. When a peer review doctor says a treatment is not medically necessary it is also not fraud, but a difference of opinion. (Of course the peer review doctor is bought and paid for by the insurance company) Or when a nurse working for an insurance company says a treatment is not medically necessary, that is also not fraud. A true medical expert (the court is the one who can determine who is an expert, by the way) might actually believe that a treatment was not medically necessary, but that also does not constitute fraud.

    A medical example: Some pediatrician are now refusing to prescribe antibiotics. Many still do. Is it now fraud when a doctor prescribes the antibiotics even though many now say it is not medically necessary?

    Or with imaging. Many physicians say that an MRI should not be done for 6 weeks after an injury yet many believe it should be done immediately, even in the absence of radicular findings. When an insurance company refuses to pay for the MRI, again, its an accusation of fraud but does not constitute fraud.

    Or is it even an accusation of fraud to refuse to pay for something which is believed by anyone, not to be medically necessary?

    In civil law suits, jury’s can be convinced of almost anything and in civil lawsuits, they don’t even have to be sure, but rather can decide on a propensity of “evidence” to decide if a doctor is liable for fraud or not. Cases like this can also precipitate disciplinary actions by licensing boards, even though the verdict is later over turned on appeal.

    Many people believe that if you don’t believe as they believe that you are a fraud, so to speak. In health care there are beliefs which abound for almost every condition/treatment. Thus folks go to the place where they feel they get the greatest help. They also want to know whats wrong with them despite what insurance companies want to pay for and other doctors think is necessary or not. And in many cases, who knows? Is there evidence? Clear cut evidence? Placebo based evidence? Maybe and maybe not.

    Bottom line is that fraud is not a thing to just throw out and accuse someone of. Many instances of “fraud” are nothing more than differences of opinion by both qualified and unqualified folks.

    In Texas the Dept of Insurance, can just lay it on you without anything more than their disagreement with your treatment plan or treatments and recommendations based upon “guidelines” which even have disclaimers which clearly state that they are just that, “guidelines” and not to be used to determine a patients care, both in type or quantity.

    Something to think about.

  88. Harriet Hall says:

    @nwtk2007,
    “Some pediatrician are now refusing to prescribe antibiotics. Many still do.”
    Nonsense! Every pediatrician prescribes antibiotics. You’re probably thinking of ear infections, where the indications for antibiotics have been narrowed but not dropped. Even when it is appropriate to not prescribe antibiotics initially, if the infection fails to resolve, antibiotics are then used. Has anyone been convicted of fraud for prescribing antibiotics for an ear infection or ordering an MRI too soon?

    You are still grasping at straws and trying to prove that differences of opinion are being labelled as fraud. Please go away and don’t come back until you have some data.

  89. lilady says:

    Drat Dr. Hall…you beat me to it! It seems nwkt2007 knows nothing, nada, zilch…bupkis about the treatment of ear effusions/ear infections.

    The people who really know about treating childhood infections…the people labeled as “sheeple” by our self-styled expert, do not treat treat with antibiotics ear infections that are usually viral in origin…it has “something” to do with the development of drug-resistant bacteria. For prolonged ear infections, antibiotics are always an option…and such treatment is always covered by private and tax-funded Medicaid health insurance.

    Give it up nwkt2007…you are out of your league here. You are making a fool’s argument.

  90. nwtk2007 says:

    Oh Harriet, that’s not what I’m trying to “prove”. Good lord.

    Its a fact. Google fraud and fraud based upon lack of medical necessity.

    Anytime an insurance company declines to pay a bill based upon another’s opinion that the services were not medically necessary, that’s an implied accusation of fraud. Ins co’s like Allstate take doctors to court to get back money paid for claims with this as their claim to juries.

    No, I’m just discussing the notion and looking to see what others takes are on it.

    This entire thread is implying that the PIP related treatments in Fla are fraudulent, because the ER doc got paid less than the Chiro’s and Massage Therapists? I just thru in an article for a bit of perspective regarding the instantaneous agreement with that notion. I really didn’t take a position at all except to point out that the MD probably saw the patient for all of 10 min for his $1800 or so.

    Then you came up with your article but I merely pointed out that just because there is an accusation of fraud doesn’t necessarily mean there is fraud and described the notion of some doctors being accused of fraud based upon the opinion of others. It doesn’t necessarily conflict with any position taken by you or the author.

    To be honest, I am a bit alarmed that you cannot chime in on a bit of that but then, aren’t you a military doctor? To me, its a worry that more folk don’t speak out about the insurance industry and their methods of forcing doctors into patterns of patient management and, in essence, determining patient care.

    Ah well. Talking to the wall I guess.

    You want a double blind study showing this practice by insurance companies et al? It ain’t there.

    What ever.

  91. Harriet Hall says:

    @ nwtk2007,

    “Anytime an insurance company declines to pay a bill based upon another’s opinion that the services were not medically necessary, that’s an implied accusation of fraud.”

    Rubbish! Now you’re just making things up. The definition of fraud implies deception. A difference of opinion about whether a treatment is necessary does not involve deception. An insurance company’s determination that they do not recognize the medical necessity of a treatment does not imply an accusation of fraud.

    Insurance companies undoubtedly have a lot of dubious practices, but that is irrelevant to the question of the relative incidence of fraud among different health care providers.

    By the way, in the original article the word “fraud” was only mentioned once, in passing, as another driver of premium increases apart from the factors discussed in the article.

  92. Quill says:

    Harriet Hall wrote: “The definition of fraud implies deception.”

    It’s actually much stronger than implication: fraud is a form of deception.

    It should be clear to any educated person who has looked at this issue that insurance companies and doctors arguing over payments for treatments rendered in no way contains an “implied accusation of fraud” as nwtk2007 seems to believe.

    There may indeed be lots-o’-fraud involved in the billing for services in personal injury cases, but the real fraud seems to me to be in non-qualifed people titled chiropractors practicing something they call medicine but which has no basis in fact, no good evidence for efficacy and no plausible mechanisms of action. Sure, some may believe in what they’re doing but there have to be at least a few that know it’s all based in nonsense.

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