It is going to take a Posse to stop Healthcare Fraud

Varmints vs. The 7 Member Posse

It's been like the Wild-Wild West, in terms of Healthcare Fraud.

I would wager that 90-something percent of Medical/ Chiropractic professionals and Dentists are law-abiding citizens.

This correspondence is intended to address the ways of those few Varmints that are messing it up for everyone:

I believe there is a simple truth – It’s going to take a Posse to stop Healthcare Fraud. Healthcare Fraud is pervasive. Recent estimates states it is costing law-abiding citizens over 10 billion dollars/ year.

Law-abiding citizens, guess who pays the tab for Healthcare Fraud -- you!

So who should be on the Posse? My vote:


You young folk out there - you are the mavens of modern technology. How about taking a short break from doing your selfies, texting your pals, or playing your favorite games (e.g., Warcraft, Candy-Crush - whatever is your 'fave'), and help grandma and grandpa out with their Insurance Statements. You only have to do it once a month. You can send an email to our staff (, and we will send you the web-links for free that you can use to make sure your grandparents are not being ripped-off. Heck - you can even score points with your parents if you do this for them...who knows, they might even increase your allowance!!!

Regular 'Working Folk'

I know you are busy 'just making ends meet'. Besides, who has the time to actually go through an Insurance Statement and try to understand 'Medical Lingo'. Here's the skinny - you are key to reviewing your Insurance Statements and seeing if what you and your Insurance Carrier are being charged is correct. Don't fall for the “Don't worry about it if the Insurance Carrier is picking up most of the tab" ruse. Look up the treatment codes - some of the treatment codes indicate a minimum duration of treatment (e.g., 15 minutes). Add the codes up that were charged for a given visit - If you are being billed for 2 hours of service and only saw the Doctor for 1 hour, even if you are not being charged directly, the money comes out of a 'pool' that is funded by you and other Insurance Members. If you ever see more than one line of charges, ask your Insurance Carrier to explain each charge, if you and your Whippersnappers can't figure it out.


Can we put politics aside, just for one minute? Many politicians tell Americans that all Regulations are bad. A good deal of the American public is being misled by this view. This view may be good for building a constituency, but it may be costing your voters money. Sometimes regulations are a good idea - for instance, it is a good idea to have a mandate that says approved Durable Medical Equipment must be regulated, stored in a free, easy to download format , and every piece of Medical Equipment must be represented by an image. If a Varmint charges grandpa and the Insurance Carrier $1000 for a Back brace, when he (the Varmint) should be using a different code and charge for what they actually provided ($50), there is no way anyone can easily tell the difference.

Insurance Carriers

As you know, your customers are charged for both Products (e.g., Durable Medical Equipment) and Services (using Diagnosis and Procedure Codes). I know you want the Insurance Statements which list the claims made to look nice. Please provide as much info on these statements as possible. For instance, if a doctor sends a bill for a DME Code = L0456, do you send your member a statement that merely says 'Orthotic Item'? If so, how will the member know they are being charged for a TLSO back brace instead of a LSO Brace (if that is what they actually received)? Odds are, most members don't know the difference between DMEs, CPTs, and ICDs and which one of them is applicable to a line item on their statement.

Also - and this is important. How many of your Insurance Members are aware of the fact that certain CPT Codes have 'fuses' attached? For instance, if a patient receives physical therapy for 15 minutes, the patient can not be billed using 2 CPT codes for a given period of time of therapy, since each CPT code designated to cover a 15 minute time interval? The same can be said about the CPT Code that is used for 'Office Visits'. If a patient has 'in-patient status' at a Hospital, I dont care how many physicians (regardless of the number of specialties) service the patient - only one 'Office Visit' should appear on a patient's bill for a given 24 hour time period.

The Skinny - inform your members of the rules associated with the codes that appear on their Insurance Statements

State Dept of Justice Decision-Makers, 'Boards' (e.g., Medical, Chiropractic, Physical Therapy), FBI Decision-Makers

At the risk of sounding Reaganesque - Tear down these walls! The jurisdictional boundaries omit opportunities for collaboration. Stories heard: "I called the FBI and they said if my case was not Medicare or Medicaid they would not touch it”; I called a 'Board' and they said it takes ~ 6 months to even get around to a Fraud complaint"; "I called the State Dept of Justice and they said the Insurance Carrier was domiciled in a different State so they couldn't investigate". Maybe it's time to 'pool your resources'? 10 Billion Bucks is a lotta loot. If we trim 10 Billion Bucks off Healthcare cost, everyone benefits!

This has been a Public Service Blog

Do you like this post?