Just Speechless......

When someone is used to committing fraud, the simplest of tasks becomes difficult.  In PA, when someone doesn't pay their parking tickets, they turn into Summary Offenses with much bigger fines then the original ticket.Guess who is not immune to this?  Since this blog is about fraud, I post this solely to help the reader get the full picture of his character.

And we are not just a single offender this year:

Fraud Update......

I have amazing news.....  My review/blog is truly paying off.  Yet another person has come forward that they identified that Dean K. Ziegler has committed fraud against them.  This person said they were googling this character to get his phone number as their cell phone was destroyed by water.  In the process, they came up against all the fraud articles and my information about Dean K. Ziegler.  I was contacted for information on what they should do next.  I kindly advised on his current probationary status with the Department of State and let them know there is already word that he is being actively investigated.  I suggested they contact the DA and report their findings and continue to go to the practice and act like nothing is wrong.  I also filled them in on completing a state complaint form to advise on what happened to them with Dean K. Ziegler of Ziegler Chiropractic.

It is so great that my word is getting out and people are learning about Dean K. Ziegler of Ziegler Chiropractic.  Thank you all for sharing in the experience.  I never felt so rewarded as I do now.  As more and more people learn about this character, the right thing will be done.

Comical Harassment update....

I was like LOL, ROLFL, (whatever those acronyms are) when I stopped by to pick up the other two Harassment complaints Dean K. Ziegler of Ziegler Chiropractic filed against me.  At his Insurance Fraud hearing, He was called a Spin Doctor and was noted for using Misdirection.  Well....  If anything, this idiot is consistent. When he was charged with fraud, he was blaming his attorney for his conviction, even though he pled guilty.  Now, He is caught again committing fraud. What he will do is when he is questioned on it he will say, LOOK, I FILLED A HARASSMENT COMPLAINT AGAINST SOMEONE WHICH MAKES ME INNOCENT.  I am so glad he is digging himself into his own hole.  The more he does, the deeper it gets.  I won't comment any more on the stupidity.... but you can make your own judgement just by reading these.  Ill put all three up including the original harassment complaint.  You will definitely get a kick out of this:

Dean K. Ziegler fraud update......

It turns out the District Attorney's insurance fraud team has been in contact with the individual that filed the complaint I spoke of earlier.  We are one step closer to ending fraud done yet again by Dean K. Ziegler of Ziegler Chiropractic.

I had spoken with two individuals of the fraud team prior.  One thing I informed them of was how he documents patient exams and works his billing processes.  He creates notes by using a bell curve when documenting patient pain scales and intensity. Then, his computer program automatically creates a note although no actual patient exam was done.  I spoke to them for a good hour and a half. I'm not going to share everything I spoke about as there is no need to divulge everything for the benefit of Dean K Ziegler if he should find out about this blog.

The individual states they had a lengthy conversation and shared much of what they noticed. Much was also colaborated with what I told them.

Dean K Ziegler of Ziegler Chiropractic may have filed three frivolous harassment complaints against me. But, he is in for it more as Karma always has a way of getting square with people.

Allentown chiropractor sentenced to prison for insurance fraud, attacking girlfriend

This is my favorite news article about Dean K. Ziegler of Ziegler Chiropractic.  It deserves a repost.

By Colin McEvoy | The Express-Times Follow on Twitter on January 26, 2012 at 12:30 PM, updated January 27, 2012 at 7:57 PM

AP File Photo

An Allentown chiropractor was sentenced to prison for defrauding insurance companies.In an unrelated case, he was also sentenced to prison for attacking his girlfriend and throwing her down a flight of stairs.
Dean Ziegler, 49, previously pleaded guilty to one count of insurance fraud, admitting he billed several companies for more than $6,000 of work he did not complete, according to court records.
Ziegler also previously admitted he broke his girlfriend's nose and threw her down the stairs at his business, which was at his home on the 100 block of South 14th Street.

"I believe I'm a good and caring doctor who always cares about my patients," Ziegler said today before Lehigh County Judge Maria Dantos.
"If I could change what happened, I would," he said. "I can only change myself and what lies ahead, and what lies ahead relies solely upon myself."

Ziegler was sentenced to four to 12 months for the insurance fraud and one to 11 months for simple assault. In all, he faces up to almost two years in Lehigh County Prison.
Ziegler requested house arrest or immediate work release so he could continue working until his chiropractor license is revoked.
But Dantos said Ziegler minimized his crimes in private with his probation officer. She said she did not believe he was truly remorseful.

"You're not as smart as you think you are," Dantos said.

She rejected the request for house arrest, and made him eligible for work release only after half his sentence is served.
Glenn McGogney, Ziegler's defense attorney, said Ziegler's girlfriend has professed her love for Ziegler since the attack and wished to be reconcile with him.
McGogney hoped house arrest would allow Ziegler to work off his $6,300 in restitution, as well as pay child support for his 9-year-old daughter in Iowa.
But Lehigh County Senior Deputy District Attorney David Mussel echoed Dantos' claims that Ziegler had not fully taken responsibility for the crime, calling him a "spin doctor."

"He's been talking a lot in circles, a lot of misdirection," Mussel said. "In a sense, judge, he thinks everyone is dumber than he is."

Ziegler was released today to take care of his affairs and work and will report back to prison Friday to begin his sentence, Dantos said.
In exchange for pleading guilty to insurance fraud, 15 related felony charges were withdrawn, according to court records.
Ziegler could have faced up to seven years for the insurance fraud charge and up to two years for the simple assault charge, according to state law.

SUPREME COURT HOLDING Snyder v. Phelps

FACTS OF THE CASE:

Fred Phelps and his followers at the Westboro Baptist Church believe that God punishes the United States for its tolerance of homosexuality, particularly within the military. To demonstrate their beliefs, Phelps and his followers often picket at military funerals.

Albert Snyder's son, Lance Corporal Matthew Snyder, was killed in the line of duty in Iraq in 2006. Westboro picketed Matthew Snyder's funeral displaying signs that stated, for instance, "God Hates the USA/Thank God for 9/11," "Thank God for Dead Soldiers," and "Don't Pray for the USA." The church notified local authorities in advance that they intended to picket the funeral, staged the picket on public land adjacent to a public street, and complied with all police instructions. Church members also sang hymns and recited Bible verses.

Although Albert Snyder could see the tops of the picket signs on the day of the funeral, he could not read what was written on them and it was not until he saw a news story about the funeral and the picketing that he became aware of the church's message. Snyder sued Phelps and the church claiming, among other things, that their actions caused him severe emotional distress. In defense, Phelps argued that his speech (the picketing and the signs) was protected under the Free Speech Clause of the First Amendment to the Constitution.   

HOLDING:

The Supreme Court's holding turned largely on its determination that the church was speaking on "matters of public concern" as opposed to "matters of purely private significance." The Court explained that "[s]peech deals with matters of public concern when it can 'be fairly considered as relating to any matter of political, social, or other concern to the community' or when it 'is a subject of general interest and of value and concern to the public.'" Speech on public issues is entitled to special protection under the First Amendment because it serves the "the principle that debate on public issues should be uninhibited, robust, and wide-open." To determine whether the speech dealt with matters of public concern, the Court examined the "content, form, and context" of the speech. The court noted that none of these factors determines the outcome of the case and that a court must evaluate all the circumstances of the speech, "including what was said, where it was said, and how it was said."

Even though some of the picket signs arguably targeted only the Snyder family, most of them addressed issues regarding the moral conduct of the U.S., the fate of the U.S., and homosexuality in the military. As such, the "overall thrust and dominant theme" of the speech related to broader public issues. Furthermore, the church was picketing on public land adjacent to a public street. Finally, there was no pre-existing relationship between Westboro's speech and Snyder that might suggest that the speech on public matters was intended to mask an attack on Snyder over a private matter. Therefore, the Court held that the Phelps and his followers were "speaking" on matters of public concern on public property and thus, were entitled to protection under the First Amendment.

Argued: October 6, 2010

Decided: March 2, 2011

Vote: 8-1

Majority opinion  written by Chief Justice Roberts and joined by Justices Scalia, Kennedy, Thomas, Ginsburg, Breyer, Sotomayor, and Kagan.

Concurring opinion  written by Justice Breyer.

Dissenting opinion  written by Justice Alito.

New Avenue of information...

As a matter of public concern, it is important that the information about the history of Dean K Ziegler of Ziegler Chiropractic get out. To get the most exposure possible I have added another website.  This will focus on just fraud related activities and this blog will entail Fraud, prevention, and harassment updates.

CLICK HERE 

Does Dean K Ziegler of Ziegler Chiropractic have a leg to stand on??

     As I eagerly await my day in court where Dean K Ziegler of Ziegler Chiropractic filed a Harassment charge against me for posting reviews and posting blogs, I realize more and more that he is full for it. The more he wants to silence me, the more I realize that things that hide under rocks don't like exposure to light and the guilty always have a need of hiding from who they are.  Of course he doesn't want people to know about his past. But as a matter of public concern, people deserve to know.
     I only hope that I am able to make a good case that he has violated Title 18 Pa. Cons. Stat. sections § 4906 (False reports to law enforcement authorities), § 4910 (Tampering with or fabricating physical evidence.), and § 4904.  (Unsworn falsification to authorities).  
     According to the order from the Department of State: 
"Respondent shall abide by and obey all laws of the United States, the Commonwealth of Pennsylvania and its political subdivisions  and all rules and regulations and laws pertaining to the practice of the profession in this Commonwealth or any other state or jurisdiction in which Respondent  holds a license  to  practice  the profession.    Summary  traffic violations shall  not constitute a violation of this order."
     Violation would result in his license probation being retracted and Dean K. Ziegler of Ziegler Chiropractic will be suspended for the remaining 5 years of the order.
     With all the information I have, I know I will prove that I committed no criminal harassment.  I have the First Amendment on my side and also the law in regards to the Harassment Statute.  The challenge will be to get him to stumble up, which might not be hard because from his Fraud Plea Hearing, he was known as the "Spin Doctor".  He never feels he does anything wrong.  As Judge Dantos said: Ziegler minimized his crimes in private with his probation officer. She said she did not believe he was truly remorseful.  His fraud history doesn't only relate to Insurance.  It also is imbedded in the very fabric of his every being.
     This hearing date can't come soon enough......

Local District attorney, Jim Martin sues a blogger....

This story came across my facebook page.  District Attorney Jim Martin is suing an individual in CIVIL court for ruining his reputation.  See....  The DAs know this stuff isn't criminal otherwise he would have filed a private criminal complaint against the blogger.  No wonder why they disapproved Dean K Zieglers' private criminal complaint against me.  I wish the morning call would do a story about my situation.

The story is in the Morning Call:

CLICK HERE TO READ THE STORY

Harassment update...

   Received a call from the District Attorneys office today.  I was informed incorrectly about how many private criminal complaints Dean K Ziegler of Ziegler Chiropractic filed against me.  Turns out he filed 3 for Harassment and all 3 were disapproved. They provided as an option, if wanted, to file a summary harassment at the magistrate on his own. But the DAs office was not getting involved. They know there is no criminal harassment involved. So now I wait for the case to be changed to another venue (As magistrate Manescu wants nothing to do with Dean K Ziegler of Ziegler Chiropractic)  and receive a court date.  I feel really worried (NOT!)

Harassment update.....

     I happen to be speaking to the District Attorneys office today.  The topic of another matter relating to Dean K Ziegler came up. It appears that two private criminal complaints were received by them against me from Dean K Ziegler.  Both of them were "disapproved".  Well go figure.......

  

The heat is on....

     Turns out another individual who read my review has checked their insurance bills.  Turns out they were charged for procedures they did not have.  It was my hopes that people learn from my experiences and protect themselves from fraud.  This individual learned for sure that all my information about Dean K Ziegler of Ziegler Chiropractic is coming true for them.  
     
   Lets see where this goes from here....

Allentown chiropractor sentenced to prison for insurance fraud, attacking girlfriend

This is my favorite news article about Dean K. Ziegler of Ziegler Chiropractic.  It deserves a repost.

By Colin McEvoy | The Express-Times Follow on Twitter on January 26, 2012 at 12:30 PM, updated January 27, 2012 at 7:57 PM

AP File Photo

An Allentown chiropractor was sentenced to prison for defrauding insurance companies.In an unrelated case, he was also sentenced to prison for attacking his girlfriend and throwing her down a flight of stairs.
Dean Ziegler, 49, previously pleaded guilty to one count of insurance fraud, admitting he billed several companies for more than $6,000 of work he did not complete, according to court records.
Ziegler also previously admitted he broke his girlfriend's nose and threw her down the stairs at his business, which was at his home on the 100 block of South 14th Street.

"I believe I'm a good and caring doctor who always cares about my patients," Ziegler said today before Lehigh County Judge Maria Dantos.
"If I could change what happened, I would," he said. "I can only change myself and what lies ahead, and what lies ahead relies solely upon myself."

Ziegler was sentenced to four to 12 months for the insurance fraud and one to 11 months for simple assault. In all, he faces up to almost two years in Lehigh County Prison.
Ziegler requested house arrest or immediate work release so he could continue working until his chiropractor license is revoked.
But Dantos said Ziegler minimized his crimes in private with his probation officer. She said she did not believe he was truly remorseful.

"You're not as smart as you think you are," Dantos said.

She rejected the request for house arrest, and made him eligible for work release only after half his sentence is served.
Glenn McGogney, Ziegler's defense attorney, said Ziegler's girlfriend has professed her love for Ziegler since the attack and wished to be reconcile with him.
McGogney hoped house arrest would allow Ziegler to work off his $6,300 in restitution, as well as pay child support for his 9-year-old daughter in Iowa.
But Lehigh County Senior Deputy District Attorney David Mussel echoed Dantos' claims that Ziegler had not fully taken responsibility for the crime, calling him a "spin doctor."

"He's been talking a lot in circles, a lot of misdirection," Mussel said. "In a sense, judge, he thinks everyone is dumber than he is."

Ziegler was released today to take care of his affairs and work and will report back to prison Friday to begin his sentence, Dantos said.
In exchange for pleading guilty to insurance fraud, 15 related felony charges were withdrawn, according to court records.
Ziegler could have faced up to seven years for the insurance fraud charge and up to two years for the simple assault charge, according to state law.

Dean K Ziegler must pay for positive reviews....

An individual who read my review pointed out something to me today.  Dean K Ziegler must pay for positive reviews.  
Look at this post from Facebook on the Ziegler Chiropractic page that was sent to me. Note that its acknowledged that he signed up with "Signpost".

Now check out this google plus review:

Clicking on the name of the individual to pull up their profile, notice the employer listed and also the location:

A fraudulent review????? Go figure...

Dean K. Ziegler of Ziegler Chiropractor does not like negative reviews...

     It seems Dean K. Ziegler of Ziegler Chiropractic has been trying hard to have my reviews removed from any site I have them on. Thats where having this blog comes into play.  I control the content based on truth.
     It is important to me that people know about his history and potential to commit fraud on them.  I have been harmed by Dean K. Ziegler and I don't want the same for others.  
     Its great the internet is available for allowing an avenue for the everyday person to be a journalist and share (via First Amendment Rights to Freedom of Speech) their experiences.

                                  This is from google plus:

     He doesn't mention the important fact that the harassment complaint is a private complaint and not one brought on by the authorities (as they are smart enough to notice real harassment when it occurs).

I guess this shows that he is using the criminal process to try and have his way with having negative reviews removed.  And that is abuse of process. 

Current License Status...

License status of Dean K Ziegler of Ziegler Chiropractic from the PA Department of State:

Permanent Record

What is Insurance Fraud? Know It to Stop It!

No Gain...Just Pain TV Spot 2013

Facts you should know when submitting a complaint...

If a "professional" has done you wrong, do not hesitate to take action.
CLICK HERE TO GO TO THE PA LICENSING BOARD WEB SITE

CLICK HERE TO PRINT THE COMPLAINT FORM

CLICK HERE TO SUBMIT YOUR COMPLAINT ONLINE

The Pennsylvania Department of State receives complaints concerning the Bureau of Commissions, Elections and Legislation, which issues notary commissions; the State Athletic Commission, which registers athletic agents; the Bureau of Charitable Organizations; and licensees and registrants of the following 29 professional and occupational licensing boards & commissions regulated by the Department's Bureau of Professional and Occupational Affairs:

Accountancy
Architects Licensure Board
Auctioneer Examiners
Barber Examiners
Certified Real Estate Appraisers
Chiropractic
Cosmetology
Crane Operators
Dentistry
Registration Board for Professional Engineers, Land Surveyors and
      Geologists
Funeral Directors
Landscape Architects
Massage Therapy
Medicine
Nursing
Examiners of Nursing Home Administrators
Occupational Therapy Education and Licensure
Optometry
Osteopathic Medicine
Pharmacy
Physical Therapy
Podiatry
Psychology
Real Estate Commission
Social Workers, Marriage and Family Therapists and Professional
      Counselors
Examiners in Speech - Language and Hearing
Vehicle Manufacturers, Dealers and Salespersons
Veterinary Medicine The Navigation Commission for the Delaware River and its Navigable Tributaries

If you believe the practice or the service provided by a licensee or registrant of the above-named boards or commissions to be unethical, immoral, below an acceptable standard of practice or out of the scope of the profession, you are urged to file a Statement of Complaint Form with the Department of State.

How to avoid chiropractic fraud

January 14, 2013 By admin

As with most cases of fraud, many people assume if they are not directly involved it has no impact on their life. Nothing could be farther from the truth. In fact, incidents of fraud in the health care industry as well as other areas of your life have a ripple affect, impacting everyone regardless of whether or not they are direct participants. Here we look at how chiropractic fraud affects everyone.

What is chiropractic fraud?

Better known as chiropractic insurance fraud, this occurs when either a recipient of chiropractic treatment or administrator of treatment misrepresents information to the insurance company regarding such treatment. A widespread problem in the medical community at large and specifically the chiropractic community, insurance fraud is a serious issue.

Who does it hurt?

Insurance fraud hurts everyone. From the patient who no longer knows where to turn for quality care to the person paying higher insurance premiums as a result of fraudulent claims. Insurance fraud has a far reaching affect on those in the medical community and beyond.

How to prevent insurance fraud?

Patients worried about insurance fraud can help stop the problem by paying close attention to the information reported to the insurance company regarding their treatment. Is the insurance provider being billed for treatments as they occurred? Is there a discrepancy in what the insurance company is billed for in relation to the treatment received? Do you feel as if you are receiving more treatments than medically necessary? These are all indications that your chiropractor may be involved in insurance fraud.

What should you do if you suspect insurance fraud?

It is believed that insurance fraud costs taxpayers upwards of 50 billion dollars per year. For this reason anyone suspecting insurance fraud should report the incident immediately. Ideally the insurance company paying out on fraudulent claims should be the first party notified, with state or federal agencies next in line. In cases of insurance fraud, you can report your suspicions anonymously or provide your name and contact information.

How to find a reputable chiropractor?

Just because there are a few bad apples in the business, does not mean all chiropractors are crooks. The opposite is true, with almost all chiropractors being legitimate members of the heath care system. Chiropractic treatments offer many benefits when administered by those with experience and proper training. Always check with the Better Business Bureau and ask for references to learn more about the chiropractor you are considering. As other patients about their experience and research the individual or practice online for an inside look at how other patients have rated their experience. It is always a good idea to follow your own instincts as well. If you feel the chiropractor in question is more concerned with billable treatments versus finding a solution to your problem, they may not be the chiropractor for you. A reputable chiropractor will always put the needs and safety of their clients above any concerns over billable treatments. Insurance fraud should be a concern for all of us, however it is important to remember that most medical professionals are in the business to provide services to those in need.

Dr. Ryan Marshall, D.C.
Tulsa chiropractors treat individuals with a variety of conditions. Dr. Ryan Marshall, D.C, a Tulsa Chiropractor, has over seven years of clinical experience treating patients of all ages. He enjoys spending time with his wife and daughter, bass fishing and playing the guitar and piano. He is also an active member of First Baptist Church Broken Arrow.

Insurance Fraud and Abuse: A Very Serious Problem

Insurance Fraud and Abuse:A Very Serious Problem

http://www.quackwatch.com/02ConsumerProtection/insfraud.html

by:  Stephen Barrett, M.D.

Fraud and abuse are widespread and very costly to America's health-care system. Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit. An example would be billing for services that are not rendered. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. An example would be performing a laboratory test on large numbers of patients when only a few should have it. Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with an intent to deceive the insurer.
Although no precise dollar amount can be determined, some authorities contend that insurance fraud constitutes a $100-billion-a-year problem. The United States Goverment Accountability Office (GAO) estimates that $1 out of every $7 spent on Medicare is lost to fraud and abuse and that in 1998 alone, Medicare lost nearly $12 billion to fraudulent or unnecessary claims [1].

Type of Fraud and Abuse

False claim schemes are the most common type of health insurance fraud. The goal in these schemes is to obtain undeserved payment for a claim or series of claims [2]. Such schemes include any of the following when done deliberately for financial gain:

• Billing for services, procedures, and/or supplies that were not provided.
• Misrepresentation of what was provided; when it was provided; the condition or diagnosis; the charges involved; and/or the identity of the provider recipient.
• Providing unnecessary services or ordering unnecessary tests [3].

Many insurance policies cover a percentage of the physician's "usual" fee. Some physicians charge insured patients more than uninsured ones but represent to the insurance companies that the higher fee is the usual one. This practice is illegal. It is also illegal to routinely excuse patients from copayments and deductibles. (A copayment is a fixed dollar amount paid whenever an insured person receives specified health-care services. A deductible is the amount that must be paid before the insurance company starts paying.) It is legal to waive a fee for people with a genuine financial hardship, but it is not legal to provide completely free care or discounts to all patients or to collect only from those who have insurance. Studies have shown that if patients are required to pay for even a small portion of their care they will be better consumers and select items or services because they are medically needed rather than because they are free. Routine waivers thus raise overall health costs. They are considered fraudulent because averaging them with the doctor's full fees would make the "usual" fees lower than the amounts actually billed for.
Other illegal procedures include:

• Charging for a service that was not performed.
• Unbundling of claims: Billing separately for procedures that normally are covered by a single fee. An example would be a podiatrist who operates on three toes and submits claims for three separate operations.
• Double billing: Charging more than once for the same service.
• Upcoding: Charging for a more complex service than was performed. This usually involves billing for longer or more complex office visits (for example, charging for a comprehensive visit when the patient was seen only briefly), but it also can involve charging for a more complex procedure than was performed or for more expensive equipment than was delivered. Medicare documentation guidelines describe what the various levels of service should involve [4].
• Miscoding: Using a code number that does not apply to the procedure.
• Kickbacks: Receiving payment or other benefit for making a referral. Indirect kickbacks can involve overpayment for something of value. For example, a supplier whose business depends on physician referrals may pay excessive rent to physicians who own the premises and refer patients. Another example would be a mobile testing service that performs diagnostic tests in a doctor's office. Kickbacks can distort medical decision-making, cause overutilization, increase costs, and result in unfair competition by freezing out competitors who are unwilling to pay kickbacks. They can also adversely affect the quality of patient care by encouraging physicians to order services or recommend supplies based on profit rather than the patients' best medical interests. In 2000, the Office of the Inspector General issued a fraud alert warning against kickbacks disguised as rental payments [5].

Criminals sometimes obtain Medicare numbers for fraudulent billing by conducting a health survey, offering a free "health screening" test, paying beneficiaries for their number, obtaining beneficiary lists from nursing homes or boarding facilities, or offering "free" services, food, or supplies to beneficiaries.

Excessive or Inappropriate Testing

Many standard tests can be useful in some situations but not in others. The key question in judging whether a diagnostic test is necessary is whether the results will influence the management of the patient. Billing for inappropriate tests—both standard and nonstandard—appears to be much more common among chiropractors and joint chiropractic/medical practices than among other health-care providers. The commonly abused tests include:

• Computerized inclinometry: Inclinometry is a procedure that measures joint flexibility. Inclinometer testing may be useful if precise range-of-motion measurements are needed for a disability evaluation, but routine or repeated measurements "to gauge a patient's progress" are not appropriate [6].
• Nerve conduction studies: These tests can provide valuable information about the status of nerve function in various degenerative diseases and in some cases of injury [7]. However, "personal injury mills" often use them inappropriately "to "follow the progress" of their patients.
• Surface electromyography: This test, which measures the electrical activity of muscles, can be useful for analyzing certain types of performance in the workplace. However, some chiropractors claim that the test enables them to screen patients for "subluxations" and to follow their progress. This usage is invalid [6].
• Thermography: Thermographic devices portray small temperature differences between sides of the body as images. Chiropractors who use thermography typically claim that it can detect nerve impingements or "nerve irritation" and is useful for monitoring the effect of chiropractic adjustments on subluxations. These uses are not appropriate [6].
• Ultrasound screening: Diagnostic ultrasound procedures have many legitimate uses. However, ultrasonography is not appropriate for "diagnosing muscle spasm or inflammation" or for following the progress of patients treated for back pain [6].
• Unnecessary x-rays: X-rays examinations can be important to look for conditions that require medical referral. However, it is not appropriate for chiropractors to routinely x-ray every patient to look for "subluxations" or to "measure the progress" of patients who undergo spinal manipulation [6].
• Spinal videofluoroscopy: This procedure produces and records x-ray pictures of the spinal joints that show the extent to which joint motion is restricted. For practical purposes, however, simply physical examination procedures (such as asking the patient to bend) provide enough information to guide the patient's treatment [6].

Many insurance administrators are concerned about chiropractic claims for "maintenance care" (periodic examination and "spinal adjustment" of symptom-free patients) , which is not a covered service. To detect such care, many companies automatically review claims for more than 12 visits. In 1999, the U.S. Inspector General recommended automatic review after no more than 12 visits for Medicare recipients [8]. Some chiropractors attempt to avoid review by issuing a new diagnosis after the 12th visit.

Personal Injury Mills

Many instances have been discovered in which corrupt attorneys and health-care providers (usually chiropractors or chiropractic/medical clinics) combine to bill insurance companies for nonexistent or minor injuries. The typical scam includes "cappers" or "runners" who are paid to recruit legitimate or fake auto accident victims or worker's compensation claimants. Victims are commonly told they need multiple visits. The providers fabricate diagnoses and reports and commonly provide expensive but unnecessary services. The lawyers then initiate negotiations on settlements based upon these fraudulent or exaggerated medical claims. The claimants may be unwitting victims or knowing participants who receive payment for their involvement [9]. Mill activity can be suspected when claims are submitted for many unrelated individuals who receive similar treatment from a small number of providers.

Quackery-Related Miscoding

In processing claims, insurance companies rely mainly on diagnostic and procedural codes recorded on the claim forms. Their computers are programmed to detect services that are not covered. Most insurance policies exclude nonstandard or experimental methods. To help boost their income, many nonstandard practitioners misrepresent what they do. They may also misrepresent their diagnosis. For example:

• Brief or intermediate-length visits may be coded as lengthy or comprehensive visits.
• Patients receiving chelation therapy may be falsely diagnosed as suffering from lead poisoning; and the chelation may be billed as "infusion therapy" or simply an office visit [10].
• The administration of quack cancer remedies may be billed as "chemotherapy."
• Live-cell analysis may be billed as one or more tests for vitamin deficiency.
• Nonstandard allergy tests may be represented as standard ones.
• Services not covered because they were performed outside of the United States may be billed as though they were performed within the United States.

Other Overbilling Schemes

In 2000, a Government Accounting Office (GAO) official told a Congressional committee how four other types of schemes are carried out:

• In "rent-a-patient" schemes, organizations pay ("rent") individuals to go to clinics for unnecessary diagnostic tests and cursory examinations. Licensed physicians sometimes participate in the rent-a-patient scheme. Insurers are billed for those services and often for other services or medical equipment never provided. In a variation of this scheme, perpetrators merely buy individual health care insurance identification numbers for cash.
• In "pill mill" schemes, separate health care individuals and entities—usually including a pharmacy—collude to generate a flood of fraudulent claims that Medicaid pays. After a prescription is filled, the beneficiary sells the medication to pill buyers on the street who then sell the drugs back to the pharmacy.
• "Drop box" schemes use a private mailbox facility as the fraudulent health care entity's address, with the entity's "suite" number actually being its mailbox number. The fraudulent entity then uses the address to submit fraudulent insurance claims and to receive insurance checks. For example, while the insurer sends payments to "Suite 478" at a certain address, payments are actually going to "Box 478" at a privately owned mailbox facility. The perpetrator then retrieves the checks and deposits them into a commercial bank account..
• Third-party billing schemes revolve around a third-party biller—who may or may not be part of the scheme—who prepares and remits claims for health care providers. The third-party biller may add claims without the providers' knowledge and keeping the remittances [11].

Bogus Health Insurance Companies

The GAO has issued two reports concerning the sale of health insurance plans that lack legal authorization. These plans place the buyer at risk for financial disaster if serious illness strikes. One report focuses on consumer vulnerability [12]. The other notes that from 2000 to 2002, 144 unauthorized entities enrolled at least 15,000 employers and more than 200,000 policyholders who got stuck for over $200 million in unpaid claims [13]. The investigatirs found that many of the entitles bore names similar to those of legitimate companies. In response to the report, the Health Insurance Institute of America is again urging the National Association of Insurance Commissioners to create an online database of licensed health insurance companies so that anyone can easily check the legitimacy of companies offering health insurance products. Meanwhile, the Coalition Against Insurance Fraud offers ten warning signs of a possible swindle:

• The coverage costs 25 percent or more below the norm, yet promises generous benefits and a large provider network.
• The plan readily accepts people with serious illnesses and other medical conditions that other plans normally reject.
• The insurance has few or no underwriting guidelines—the agent or rep appears almost too eager to sign you up.
• You're approached by an insurance agent, phone or direct mail. Honest group plans normally are sponsored by your employer—and aren't sold directly to individuals.
• The plan isn't licensed in your state, and the agent (falsely) assures you the federal ERISA law exempts the plan from state licensing.
• The plan seems like insurance, but the agent or rep avoids calling "insurance," and instead uses evasive terms such as "benefits."
• The agent or rep doesn't have clear answers to your questions, seems ill-informed, or avoids sharing information.
• You've never heard of that health insurance company—and nobody else has, either.
• You have to join an "association" or "union" to obtain the health coverage. But you get no voting rights, receive no bylaws or other material, and aren't involved in the group's activities.
• Your hospital keeps calling you to complain that your health plan isn't paying your medical bills. Often the plan's reps keep making flimsy excuses, or stop returning phone calls altogether [14].

Viatical Fraud

In a viatical settlement transactions, people with terminal illnesses assign their life insurance policies to viatical settlement companies in exchange for a percentage of the policy's face value [15]. The company, in turn, may sell the policy to a third-party investor. The company or the investor then becomes the beneficiary to the policy, pays the premiums, and collects the face value of the policy after the original policyholder dies. Fraud occurs when agents recruit terminally ill people to apply for multiple policies. They misrepresent the truth and answer "no" to all of the medical questions. Healthy impostors then undergo the medical evaluation. In many cases, the insurance agent who issues the policy is a party to the scheme. The agent or one applicant may even submit the same application to many insurance companies. Viatical settlement companies then purchase the policies and sell them to unsuspecting third-party investors. The insurance industry is the biggest victim of this fraud [16]. Some investors receive nothing in return for their "guaranteed" investment.

Anti-Fraud Programs

Several large insurance companies have joined forces through the National Health Care Anti-Fraud Association to develop sophisticated computer systems to detect suspicious billing patterns. The Federal Bureau of Investigation (FBI) and the Office of the Inspector General (OIG) each have assigned hundreds of special agents to health-fraud projects. The Coalition Against Insurance Fraud, a public advocacy and educational organization founded in 1993, includes consumers as well as government agencies and insurers.
The Omnibus Consolidated Appropriation Act of 1997 authorized a Health Care Anti-Fraud, Waste, and Abuse Community Volunteer Demonstration Program to further reduce fraud and abuse in the Medicare and Medicaid programs. The program enrolled thousands of retired accountants, health professionals, investigators, teachers, and other community volunteers to help Medicare beneficiaries and others to detect and report fraud, waste, and abuse. The Health Insurance Portability and Accountability Act of 1996 funded a similar program that trained community agency workers [17]. This act also gave the U.S. Inspector General jurisdiction over private insurance plans as well as public ones.
The Inspector General's office has recovered over a billion dollars through fines and settlements. Its Operation Restore Trust, which began in 1995, was a joint federal-state program aimed at fraud, waste, and abuse in three high-growth areas of Medicare and Medicaid: home health agencies, nursing homes, and durable medical equipment suppliers. The questionable activities included:

• Billing for advanced life support services when basic life support was provided. Documentation may be falsified to indicate a patient needed oxygen—which is a key indicator in establishing medical necessity for advanced life support.
• Billing for larger amounts of drugs than are dispensed; or billing for brand-name drugs when less expensive generic versions are dispensed.
• Billing for more miles than traveled for transportation.
• Falsification of documentation to substantiate the need for a transport from a hospital back to the patient's home. Medicare will only cover transport from hospital to home if the patient could not go by any other means.

Allstate Insurance Company announced that during 2004, judges and juries around the country awarded the company more than $30 million in damages resulting from insurance fraud schemes against the company—the result of a campaign Allstate began in 2001 to go after the pocketbooks of fraud perpetrators in court. Since that time, the company has gotten more than $55 million in judgments against criminals that range from individuals to sophisticated organized crime syndicates. Unfortunately, bankruptcies and money laundering make it difficult to collect such awards. In February 2005, Allstate reported that only $5.24 million out of the $30.81 million awarded in 2004 had been recovered [18].

What You Can Do

Many frauds can be detected by examining insurance payment reports to see whether they accurately reflect the services rendered. Suspicious reports involving a private insurer claim should be reported to the company's fraud department. Suspicious practices involving Medicare or other federal programs should be reported to the OIG Hotline by phone (1-800-368-5779) or e-mail.

Recommended Publications

• Fraud Trends Update
• Millin's Health Fraud Monitor

Other Information Sources

• Aetna US. Healthcare Coverage Policy Bulletins
• American Association of Retired Persons
• Coalition Against Insurance Fraud
• How to Spot a Personal Injury Mill
• Medicare Fraud Prevention Tips
• Department of Justice Health Care Fraud Report (1997)
• Department of Justice Health Care Fraud Report (1998)
• Health Insurers' Anti-Fraud Programs Research Findings (1999)
• The Illusion of Group Health Insurance: Voluntary Associations
• Insurance Fraud Case Reports on Chirobase
• Medicare Coverage Issues Manual (lists many noncovered products and procedures)
• National Insurance Crime Bureau
• OIG Exclusions Database: (individuals/entities excluded from federally funded health-care programs)
• OIG Semi-Annual Reports

References

1. Department of Justice Health Care Fraud Report, Fiscal Year 1998. Washington, DC: Department of Justice, 1999.
2. BlueCross & BlueShield United of Wisconsin. What is health care fraud? Accessed Nov 30, 1999.
3. Guidelines to health care fraud. Adopted by the National Health Care Anti-Fraud Association Board of Governors, Nov 19, 1991.
4. 1997 Documentation guidelines for evaluation and management services , Centers for Medicare & Medicaid Services, 1997.
5. Rental of space in physician offices by persons or entities to which physicians refer. OIG Special Fraud Alert, February 2000.
6. Homola S. Inside Chiropractic: A Patient's Guide. Amherst, NY: Prometheus Books, 1999.
7. Campbell WW and others. Recommended policy for electrodiagnostic medicine. American Association of Electrodiagnostic Medicine, Sept 26, 1996.
8. Brown JG. Utilization parameters for chiropractic treatments. Washington, DC: Office of the Inspector General, Nov 1999.
9. Stern RA, Montana R. Identify patterns of medical provider fraud through data base graphic pattern. FDN Fraud Report, Nov 1999.
10. Barrett S. Chelation therapy and insurance fraud. Quackwatch, May 8, 2000.
11. Hast RH. Health care fraud: Schemes to defraud Medicare, Medicaid, and private health care insurers. Testimony before the Subcommittee on Government Management, Information and Technology, Committee on Government Reform, House of Representatives. GAO/T-OSI-00-15, July 25, 2000.
12. Private health insurance: Employers and individuals are vulnerable to unauthorized or bogus entities selling coverage. #GAO-04-312, Feb 2004
13. Private health insurance: Unauthorized or bogus entities have exploited employers and individuals seeking affordable coverage. #GAO-04-512T, March 3, 2004.
14. Scam alert. Coalition Against Insurance Fraud Web site, accessed March 5, 2004.
15. Viatical settlements. FTC, 1998.
16. Kohtz DA. Viatical fraud. Quackwatch, Aug 16, 2000.
17. Implementation of the Administration on Aging's health care fraud and abuse programs: 18-month outcomes. Washington, DC: Office of Evaluations and Inspections, Aug 1999.
18. Fraudsters ordered to pay allstate more than $30 million in '04. Allstate news release, Feb 14, 2005.

This article was revised on January 10, 2006.

Nine Rules and Procedures to Prevent Insurance Fraud

Nine Rules and Procedures to Prevent Insurance Fraud
(For the patient to know how your doctor, especially Dean K Ziegler of Ziegler Chiropractic, should be handling their billing practices.  Be on the look out.......)
By Michael J. Schroeder, Esq. and David S. Singer
Dynamic Chiropractic – October 24, 1990, Vol. 08, Issue 22

A doctor decides to help his cash patients by doing physical therapy at no charge. A doctor decides to give a new patient without insurance a reduced fee for an examination. A doctor decides to forgive the deductible and/or reduce the co-payments for certain patients.

A doctor has a patient who initially hurt himself at home but aggravated it at work; the doctor bills this through Workers' Compensation. 

Any of the above examples could constitute insurance fraud. 

There is a nationwide attempt to reduce health care costs. Some of the more common techniques employed by the insurance industry are: 

1. Sending investigators acting as patients


2. Creating computer profiles of average office visit fees and average case costs, and then identifying doctors who significantly exceed these averages


3. Pressing civil and criminal charges against doctors who engage in abusive practices


4. Publicizing civil and criminal charges of insurance fraud


5. Pursuing the enactment of new laws reducing chiropractic coverage


6. Forcing doctors to compromise personal injury liens 

To Prevent This from Happening to You, Follow These Rules: 

Rule 1: Create Patient Protocol Based on Diagnosis Or Extent of Injury -- Not Cash Versus Insurance Patients.

Despite how this might upset some doctors philosophically, the moment a doctor agrees to accept income from insurance, he has entered into a system based on the medical model of health care. Diagnosis and the degree of injury alone should determine the type of care and number of visits. Thus, the following example would not be legal: 

A person with a flexion/extension injury as the result of an auto accident comes to the doctor with insurance coverage. The doctor takes six x-rays and does a comprehensive examination charged at $85. The same doctor sees another patient who hit his head in the pool. This patient also has a flexion/extension injury but has no insurance. The doctor takes only two x-rays and does a brief examination for $25. 

The problem with this approach is two-fold. First, the doctor has represented that his fee for a flexion/extension injury examination is $85. If this is the "customary charge," then the doctor should charge the same fee and perform the same service for the cash patient. When a doctor accepts a lower fee from a cash patient for a similar service as that given an insurance patient at a higher fee, that is two-tier billing and that is illegal. 

If the doctor wishes to offer a service such as a comprehensive examination to a cash patient and the patient wishes to decline that service, the doctor must make careful note of this in his records. A patient has the right to decline any treatment or diagnostic service. What is important is that the doctor offers the same service regardless of insurance. 

The second problem is the difference in the diagnostic approach between the two patients in regard to x-rays. The above example would imply the doctor treated the patient's insurance policy rather than the patient. Malpractice exposure is also created if a doctor takes only two x-rays on a flexion/extension injury when his normal procedure would be to take five. Once again, the doctor should have recommended five views and given the patient an option to refuse. If the patient refused, this would need careful notation in the patient's records. 

Rule 2: If a Patient Is in Financial Need, Have Him Put This in Writing Before Offering a Discounted Fee.

If a patient tells you that he truly cannot afford to receive care, you may wish to treat this patient at a reduced fee. If this is done without the patient putting something in writing, the variation in fees could be questioned long after the patient has gone or moved. A doctor's statement that he was just helping a patient does not avoid the charge of insurance fraud. 

Additionally, many doctors mistake the ability to offer a reduced fee to the truly needy as authorization to classify all of their cash patients as "needy." When a doctor offers discounts to substantially all of his cash patients based on "need," the same discount must be given to insurance patients. 

Rule 3: Have Patients Sign in For Each Visit and Keep These Records For at Least Seven Years.

A disgruntled patient may claim that the doctor billed him for treatment that never occurred. The only proof the doctor has is his records. A patient's own signature showing he was in the office is the best proof. This will also help the doctor to defend himself in a malpractice action. In fact, if the doctor is treating children, these records must be maintained for seven years after the child becomes an adult. 

Rule 4: If You Find You Have Made An Error in Billing, Notify the Insurance Carrier.

A doctor discovers his new insurance staff has billed all patients as having had therapy each visit when they did not. The staff did this in error. The doctor should correct his staff's mistakes and immediately notify the insurance company of the error and its cause. Not only will this make it unlikely that the insurance company will take any further action against him, but it also undercuts the ability of the insurance company to accuse the doctor of fraud. Intent to defraud is a required element of any fraud claim, so if the doctor voluntarily alerts the insurance company of a mistake made, it looks much more like what it was -- an innocent mistake. 

Rule 5: If You Receive Overpayment, Return It.

A doctor receives two payments for the same service from one insurance carrier, or receives two payments from two carriers for the same service. The doctor must return one of the checks to the insurance company. The only exception would be if the patient carried two private pay insurances that allowed double billing; then one payment goes to the patient. 

Rule 6: Family Plans Are Illegal Unless the Same Procedure Is Afforded to Both Insured and Cash Patients.

If a doctor gives cash patients one fee for the first patient and a lower fee for the other family members, then that doctor would have to give another family who were all in an auto accident the same low fee. As discussed previously, two-tiered billing is not legal. A safe family plan would be all children under the age of ten are seen once per month at no charge. Thus cash or insured children are not charged when they come but once per month. 

Rule 7: Maintenance Care Cannot Be a Lower Fee Unless Given to Insurance Patients on the Same Frequency.

As discussed above, two-tiered billing is simply not legal whether it is justified on cash/insurance grounds or on maintenance/treatment grounds. Once again, special hardships are permissible. However, if all cash patients appear to be under hardship, the spirit of the law has been violated and the doctor's customary fee could be interpreted as the lower fee. Thus all higher billings to the insurance company could be construed as overbilling. 

Rule 8: Advertising No-Out-Of-Pocket Expense (Insurance Accepted As Full Payment) Is Illegal in Various States.

In many states, the insurance companies take the approach that if your normal fee is only 80% of what you bill, they will pay only against 80%. Thus, they pay 80% of 80%, i.e., 64%. In some states, the chiropractic boards are now requiring their licentiates to disclose to the insurance company each time a deductible or co-payment is forgiven. 

Rule 9: Working with a Medical Doctor May Violate State and Federal Laws.

A chiropractic doctor and a medical doctor can work together; however, proper legal planning is essential. A chiropractor cannot accept any form of kickback for a referral to such an MD In the case of Medicare, this could be considered Mail Fraud. Anyone wishing to create an integrated chiropractic and medical facility should get sound legal advice in writing before proceeding. 

In conclusion, a doctor must know the rules of the game. Failure to know the law does not exempt you from it. There is a legal way to accomplish your desire to serve and help people. Be sure to balance you desire to help with proper legal procedures. 

We wish you success and a trouble-free practice, and hope that these rules will serve as a good guideline.

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Michael Schroeder has formed more than 300 chiropractic-medical practices since 1982. He is the current vice president and general counsel for the American Acupuncture Council, and for the last twelve years has been the vice president of the National Association of Chiropractic Attorneys (NACA). In 1995, NACA honored Mr. Schroeder as their "Attorney of the Year."