Reed,
As for “anyone” being able to bill insurance companies, where I am at
least, unless you hold a valid certification recognized at a nation level
it won’t happen…not with any company!! Every insurance company has a
formal contracting process, and part of that is credentials
identification and recognition. Are their some who have worked the loop
holes successfully (surgical suppliers…pharmacies) , absolutely…and
these loop holes need to be tighten (ie eliminated). But through
education of the public and their insurers, not legislation of an
industry by the state or federal government.
As for ABC or any other credentialing body not having any teeth, you have
a good argument. Had they exercised their muscle, and taken a few bites
out of people’s hides instead of hiding their heads in the sand, we
wouldn’t be where we are right now.
And as for seeing fraud ignored, join the club. Just one example…I was
refused reimbursement by Medicare for the adjustments/repairs on a CASH
orthosis. Why? Because the previous provider (ABC practitioner/ABC
facility) had upcoded the original billing, and as far as Medicare was
concerned this patient (on paper) doesn’t have a CASH orthosis. Medicare
will not pay for adjustments/repairs on an orthosis their paperwork shows
she never received (I was informed this during a telephone appeal with
Medicare). When I explained to the Medicare appeals lawyer that the
patient is in front of me, she is wearing a CASH orthosis, and she NEVER
received any other spinal orthosis from the previous provider, Medicare’s
solution was to tell me to take pictures, obtain statements, and track
down the original billing information to validate my information…GET
REAL. They are the governmental agency ALREADY in place to address
these issues of fraud and abuse, and they ALREADY have laws in place to
do so, and the power to do so, but apparently not the will to do so. How
will creating a governmental licensure prevent more fraud if the agencies
already in place aren’t willing to get it done. I am at least as
frustrated as you. The do’s and don’ts and the power to enforce them
already exist. I have numerous manuals from numerous insurance
companies, with hundreds of pages of regulations that I’m supposed to
follow under penalty of anti-fraud laws if I screw up.. More regulations
scare me both financially, and from a mere operations view point.
But hey…maybe your right. Maybe it’s too late to do any effective
repair of our own house. Maybe we need government to step in so we can
run as efficiently as the Congress, or with as much integrity as the
White House. Maybe that is the solution. I hope we can muster up enough
courage to put away our petty infighting and move this profession up a
few notches…our patient population deserves no less.
Mike M.
On Fri, 04 Feb 2000 00:09:19 -0600 Reed Coleman
> Mike,
>
> How do you propose we ‘police’, ‘self clean from within’ if no rules
> or
> legislation is in place to do so ???? What good does it do to
> identify
> the ‘culprit’ if you cannot ‘serve’ them the sentence ???? Pardon
> me,
> but being sanctioned by A.B.C. does not scare me at all. (B.T.W. – I
> stay completely on the ‘right side’ of the rules ). How can their
> sanctioning affect me ???? I do not have to be certified to bill
> M-care
> or other insurances.
>
> I personally have turned in individuals/companies for
> fraudelent/abusive
> practices to HCFA and the D-MERCS with DOCUMENTATION and had the
> insured
> member both call and put the situations in writing. Guess what???
> I
> AIN’T SEEN NOTHIN’ YET !!!! ( over 6 1/2 years since the first
> report
> ). I am about to turn in an other individual & his company, and I
> can’t
> help but think I’m wasting my time and effort.
>
> If laws are enacted with specific does and don’ts, then the
> fraudelent
> and abusive practices can be stopped. If you don’t think so, go
> out
> and break any of the ‘laws’ on the books and get caught. I
> gaurantee
> you will pay the appropriate penalty. Only when penalties are
> imposed
> that mean something can you put a stop to the abuse. Laws on the
> books,
> now we as a profession can POLICE OURSELVES. Until then, we have to
> rely on another body or agency to do the ‘policing’ for us. Sorry
> Mike,
> until then it is basically out of our hands.
>
> Respectfully,
>
> E. Reed Coleman, L.P.O., C.P.
>
>
>
