The Advent of a New Era in Management Consulting?
WEST VIRGINIA: The prosecution of Ron Halstead, DC, and two other chiropractors who scammed more than $2.8 million from Medicare and private insurers sends a message that health care fraud will not be tolerated, federal authorities say.
William C. Filcheck, of Morgantown, WV, Scott Taylor, of Mannington, WV, and Ronald L. Halstead, of Scottsdale, AZ., were sentenced on June 4, in U.S. District Court in Clarksburg for their roles in the scheme. Halstead, 65, received a 10-year, one-month sentence while Filcheck and Taylor were each sentenced to three years and one month.
U.S. District Judge Irene M. Keeley also ordered Filcheck and Taylor to forfeit $1.9 million.
“The significant prison sentences in this case reflect how seriously the federal criminal justice system treats health care fraud of this magnitude,” said Robert H. McWilliams, Jr., criminal chief for the U.S. Attorney’s Office for the Northern District.
Dr. Robert B. Burns, Jr., the owner of the Morgantown clinic where the chiropractors worked also has been charged, but is in Ireland. His expedition is pending, U.S. Attorney Thomas Johnston’s office says.
“This is a message to all medical practitioners that health care fraud is on the radar screen of IRS Criminal Investigation as well as other law enforcement agencies,” said Charles Jenkins, special agent in charge with the Internal Revenue Service Criminal Investigation field office in Louisville, KY.
Filcheck, Taylor and Halstead were convicted in February 2003 of engaging in a conspiracy from September 1993 to May 1997 in connection with the operation of a clinic employing both medical doctors and chiropractors.
The indictment said the men submitted or caused to be submitted false claims to private insurance companies and Medicare for tests, treatments and other services they said were performed by medical doctors who determined medical necessity, but the services were performed by chiropractors trying to evade some health care benefit programs’ limits on chiropractic care, federal authorities say.
Halstead, a consultant, advised the other defendants.
The three were also found guilty of 14 counts of executing the scheme. In addition, Halstead was found guilty of engaging in a money-laundering, conspiracy and 10 counts of specific money-laundering transactions.
– Rob Sherman
Chiropractors Sue Blue Cross, Claiming Discrimination Enough!
MICHIGAN: Some chiropractors claim that Blue Cross Blue Shield of Michigan is discriminating against them by unfairly limiting the number of visits for which a person can get reimbursed. In some cases, chiropractors who allow and bill for too many patient visits even get dropped from the Blue Cross network, The Daily Oakland Press has reported. The result, the chiropractors contend, has been financial loss for doctors and poor health care for patients.
Chiropractor Eric B. Herfert, and an associate, Dr. J.R. McCanse, have filed a lawsuit in Circuit Court seeking financial relief as well as an order requiring Blue Cross to halt its practices.
Meanwhile, in March of this year, the Michigan Chiropractic Association filed a separate suit in Ingham County with similar claims.
Blue Cross officials say the lawsuits are groundless and are adding needless costs to health care.
“They (the lawsuits) have nothing to do with health care but are merely an example of ongoing efforts by some chiropractors to maximize their reimbursement from Blue Cross Blue Shield of Michigan,” says a Blue Cross spokeswoman.
Herfert says the insurer is trying to control how patients are treated.
“(Blue Cross) is trying to prevent me and other chiropractors from properly examining and caring for our patients by restricting how they pay for various chiropractic procedures,” Herfert says. “Chiropractic care is all about restoring proper function to the nervous system and allowing your body’s own healing powers to work without interference.”
Herfert and McCanse were dropped from the Blue Cross network. They seek to return to the Blue Cross program as health care providers, to get paid for money lost and to change how Blue Cross treats patients who seek chiropractic care.
“Chiropractic care provides an alternative to medicine that many times is more effective and costs less,” Herfert says.
The association lawsuit has similar complaints, but officials stress it is a separate legal action.
“As a profession we’ve been discriminated against by Blue Cross for years,” says Ken Hughes, DC, president of the association. “All we want is a level playing field and to have Blue Cross stop messing with our patients.”
– Associated Press
Chiropractor Wins $7.6 Million Appeal
CALIFORNIA: A federal appeals court upheld $7.6 million in damages in late June for a Berkeley chiropractor who said she lost her home and went on welfare when her benefits were cut off by the world’s largest disability insurer after she was no longer able to work.
Joan Hangarter’s lawyers say her case helped expose UnumProvident Corp.’s nationwide practice of boosting its profits by terminating legitimate disability claims from policyholders who were usually too weak to fight back.
A company spokesman for the insurance carrier called that assertion “hogwash’’ and said UnumProvident paid more than $5 billion in benefits last year, “hardly the makings of a company intent on systematically denying claims.’’ He said the company disagrees with the ruling but hasn’t decided on its next step.
Hangarter was a chiropractor in Berkeley for 20 years but became unable to treat patients in 1997 because of painful repetitive-stress injuries to her arm and neck, aggravated by an auto accident.
Her insurer paid her $8,150 a month for 1½ years but then stopped, saying a medical examination it commissioned showed she was not disabled. Hangarter, a single mother of two, said she was evicted from her home, lost her car, went on welfare and declared bankruptcy when a later business venture failed.
The doctors who treated Hangarter testified that she was unable to work. Other witnesses testified on her behalf that internal documents revealed an UnumProvident policy of terminating disability claims without regard to their merits. A federal jury ruled in her favor in February 2002 and awarded damages for lost benefits and emotional distress and $5 million in punitive damages.
In its appeal, the company argued that Hangarter was not totally disabled because she performed clerical tasks and managed her office from 1997 to 1999. But the court noted that Hangarter had an occupational disability policy—which provided benefits if she became disabled from her occupation—and said California law defined Hangarter as totally disabled because she was unable to work as a chiropractor.
The jury was also entitled to find that the company conducted a biased investigation and acted in bad faith, justifying punitive damages in the ruling.
– San Francisco Chronicle
Insurance Fraud Rings BUSTED!
CALIFORNIA: Two sisters who owned legal clinics in San Jose were indicted in early July on multiple felony counts for allegedly embezzling funds from their clients’ insurance settlements and for receiving kickbacks from chiropractors for client referrals, among other charges.
The indictments against Ellen Nguyen, and Genny Nguyen are the latest developments in a case that involves what prosecutors are calling one of the longest running and most successful insurance fraud rings in the county.
Also indicted were chiropractors Jonathan Tri Lien, and Lenard Linh Nguyen, who allegedly solicited clients to file personal injury claims against auto insurance companies.
Ellen Nguyen was indicted in October 2003 on charges that she filed numerous fake insurance claims with the help of associates.
The indictments announced this July, which allege that the Nguyen sisters stole more than $120,000 between 2002 and 2003 and received more than $155,000 in kickbacks, stem from information gathered during the original investigation.
If convicted of all charges, Ellen Nguyen faces up to 74 years in prison and Genny Nguyen faces up to 32 years in prison.
No whirlpool, no good!
NORTH CAROLINA: A chiropractor indicted on offenses related to health care fraud was indicted by a federal grand jury in April on 511 counts of health care fraud, one count of conspiracy to commit health care fraud, two counts of obstruction and one count of money laundering. He and his lawyer appeared in court in late June for hearings on several motions.
Steven Ira Cohen was previously indicted in November 2003 on 21 counts of mail fraud and 16 counts of health care fraud. Those charges and the April indictment will be consolidated into one case for trial, but no trial date has been set.
The indictments accuse Cohen of submitting fraudulent claims for services that were not provided, falsely claiming that procedures were administered by medical doctors, and double-billing health care benefit programs between July 1998 and January 2003. The indictments also allege fraudulent claims were filed with multiple insurance companies, including Blue Cross Blue Shield, State Employees Health Plan, Nationwide, Aetna and State Farm.
Cohen conspired with others to “make as much money as possible by submitting materially false and fraudulent claims to the insurance companies and the Standard Corporation,” the April indictment states.
Some of the claims submitted were for patient treatment using a whirlpool, according to the April indictment. The clinic did not have a whirlpool, the indictment states.
According to the court papers, the gross proceeds of the illegal acts were $1.5 million for the 515 charges in the April indictment.
That’s much more than the amount alleged to have been gained from the activities covered in the first indictment. Those 21 counts of mail fraud and 16 counts of health care fraud were based on allegations of falsely billed services involving one family between July and October 1998.
According to the first indictment, the claim forms, submitted to the United States Department of Labor, Office of Worker’s Compensation Program and Blue Cross Blue Shield, claimed payment for services not provided and billed at the higher rate used for medical doctors rather than chiropractors. The indictment lists those gross proceeds as $6,211.
– The Daily Reflector