This is an epic struggle that spills over into many disciplines: Environmental Disease, Bio-identical Hormones, Mold, Lyme Disease, Spine Surgery, Pain Management, Vitamin and Nutritional support and more.
The “Cartel” (the coalition of insurance carriers, employers, and any other group which benefits from retained premiums) is retaining premiums by aggressively attacking the recipients of benefits (doctors and patients), with special care to keep the attack away from judicial law and within administrative law. This, of course, requires the overt complicity of government agencies as well as “medical experts” who are hired guns. Laws have to be written, rules have to be promulgated. The lobbying effort must be gargantuan.
“If they cannot test or treat, they cannot testify.” This issue needs to be expressed in terms of the way industry looks at this problem. We physicians are often dumbfounded- not that a carrier wants to deny payment of benefits in order to increase profits, but that the methodology to do so involves manufacturing a sham standard of care to support that denial- a standard of care that allows simultaneous attack on the physician providing the denied care.
Because of the current system, when the professional physician or scientist is attacked, he often expends incalculable effort to defend himself against a machine designed to “produce results”- i.e., a disciplinary action. For example, the Texas Medical Board was instructed by the Legislature in 2004 to increase its percentage of disciplinary actions from 10% to 18% (reference: “Review of Texas Medical Board Discipline” Texas Medical Association 2006 at: http://www.texmed.org/uploadedFiles/Global_Media/ReviewTMB_discipline.pdf).
This arbitrary mandate for an increase in actions feeds coincidentally into your expose’ of how practitioners can be intimidated- obviously, only by turning trivial and irrelevant complaints into “results” could an agency comply with such an arbitrary request.
As an interesting thread, please review some of the settlement documents in the Blue Cross class action lawsuit at:
http://www.hmosettlements.com/
and
http://hmosettlements.templates.ncmedsoc.org/settlements/bluecross/Mailed%20Notice-v15%20(H794)--FINAL.pdf
Note especially the paragraphs describing the allegations, which could easily be applied to the scenario that we are describing:
II. WHAT IS THIS LITIGATION ABOUT?
The Complaint in the Action alleges, among other things, that between 1999 and the present, the Blue Parties, among others, engaged in a conspiracy to improperly deny, delay, and/or reduce payments to physicians, physician groups, and physician organizations by engaging in several types of allegedly improper conduct, including but not limited to:
• Misrepresenting and/or failing to disclose the use of edits to unilaterally “bundle,” “down code,” and/or reject claims for medically necessary covered services;
• Failing to pay for “medically necessary” services in accordance with member plan documents;
• Failing and/or refusing to recognize COPT® modifiers;
• Concealing and/or misrepresenting the use of improper guidelines and criteria to deny, delay, and/or reduce payment for medically necessary covered services;
• Misrepresenting and/or refusing to disclose applicable fee schedules; and
• Failing to pay claims for medically necessary covered services within the required statutory and/or contractual
time periods.
The Complaint in the Action claims that the conduct described above violated the federal statute entitled the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. § 1961, et seq.”
As we have discussed before, the Cartel’s complex efforts include the use of manufactured or “improper” guidelines to “deny, delay and/or reduce payment”. They continue to use this highly sophisticated mechanism to this day.
