Dr. Andy

Reflections on medicine and biology among other things

Friday, March 11, 2005


This just boggles the mind:

an elaborate insurance scheme in which thousands of patients from 40 states had been transported to California to undergo unnecessary surgical and diagnostic procedures for which doctors filed more than $1 billion of fraudulent insurance claims
Apparently, patients were paid $200-2000 each and got a series of procedures, typically colonoscopy, upper GI endoscopy and some sort of procedure to treat sweaty palms, perhaps ligating a nerve?

First of all, who would undergo all this stuff for that kind of money and what made the doctors think they would get awasy with this? I mean they had to figure eventually they'd get caught.

It was just 21 doctors according to the article, meaning they'd have to generate charges of almost $50 million/doctor, which seems high. Maybe by spreading it out among patients from different states they figured no individual insurer would catch on how high their volume was. Of course, I would think an insurer in, say Texas, would find it odd to be paying out a ton of money to doctors in California.


At 9:26 AM, Anonymous jb said...

The real big money isn't in the doctor's fees, it's in the facility fees, which run into the $thousands for many of these procedures. The owners of the facilities, probably outpatient surgery centers, are the ones who really cleaned up. The $50 million still seems high, but the Times likely is using "retail" charges, not reimbursements, which would again be several times the allowables paid.

I'm not defending the docs, who should be jailed for long periods of time if they willingly participated, and in many cases the docs are the ones who own the centers. They give us all a bad name.

Other points: The sweaty palm procedure was a thoracoscopic sympathectomy. It decreases sympathetic nerve stimulation to the hands, and is occasionally indicated for this problem.

As to why the insurers in one state did not notice why so many charges were going out of state, it's because they are all concentrating on trying to prevent me from getting needed imaging or lab tests on my real patients with real problems.


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