27 Wolcott Street, Everett, MA, 02149
Dr. Haberstroh, as a result of a rather long and challenging career as an active practitioner in addition to being a "seminar junkie" for much of that time, became a leading expert in case documentation and how to defend a clinical case in the event of a challenge to the patient file. Being an active field practitioner, he understands the frustration felt by all doctors by the often innacurate assaults on case files by paid "examiners." The "examiners" Dr. Haberstroh refers to are the paid doctors who are either hired by the insurance companie or farmed out by intermediaries directly to the insurance companies to allegedly examine patients and/or their case files and render an "objective" report on the clinical situation of that patient. The unfortunuate reality is that for years, these examiners were largely agenda driven suppicants with one conclusion in mind: to cut off the patient from further care.
Dr. Haberstroh started a Chiropractic Consulting Service called IME MONITORS. For the uninitiated, IME is the commonly used contraction in the industry and it stands for Independent Medical Examination. He has worked at changing the phrase to IE which simplifies the expression to "Independent Examiner" and/or "Independent Exam." As of August, 2006 yet another term has come into vogue; DD = Defense Doctor. As of 7/2007, we began seeing the phrase "Defense Exam" or "Insurance Defense Exam." Since DCs and MDs take part in this insurance phenomena, including the word "medical" in the original phrase has become somewhat oxymoronic when a chiropractor examines a file and/or a patient.
In any event, Dr. Haberstroh developed a set of Forensic Examination procedures that examines the insurance examiners; their methods, cited materials (if any), their credentials, algorithmic arguments and previous case reports. Together with the clinical documentation paradigms established, the Forensic Exam of the Independent Examiners takes on a whole new meaning. Dr. Haberstroh regularly lectures on this as well as consults and advises with private practitioners. Recently, as of early 2010, Dr. Haberstroh was asked to be part of the revamped Peer Review Committee in association with the Mass. Chiropractic Society. At least one active Board of Registration member is on that same committee.
Recent State Supreme Court decisions have confirmed what Dr. Haberstroh, as well as many practitioners, have been saying for years, that the IE phenomena in the U.S. needs monitoring and a set of standards that IEs must be held accountable to. The patients are the ones often suffering from abridged care mandated by substandard reviews.
*(See Baum, K, Independent Medical Examinations: An Expanding Source of Physician Liability, Ann. of Int. Med., Vol. 142, Issue 12, 6/2005; Bourhis, R, BAD FAITH: FRAUD in the insurance industry, www.corpwatch.org, 8/24/05; also, Gold, L, The Doctor-Patient Relationship and Liability in Third-Party Evaluations for Civil Litigation, Psychiatric Times, Vol. 23 (7), 6/06.), Berkeley R, "Don't Fall into These Liability Traps," Med Econom Dec. 2003; 80(31). See also, the American Medical Association: CODE OF ETHICS. As well, add this recent case to your list; Harris v. Kreutzer, Circuit Court of the City of Newport News, Jan. 13, 2006, Justice H. Vincent Conway, Jr. presiding.
Dr. Haberstroh is a Boston Chiropractor.
FORENSIC: investigations of or for use ultimately in court. Forensic(s) is the art or practice of formal debate and argument. Archimedes, pictured at right, is credited with being the first documented forensic examiner. He was a brilliant mathematician and is considered to this day, one of the three greatest mathematicians that ever lived, along with Gauss and Newton. He was Sicilian and worked for King Hiero II of Syracuse. King Hiero was suspicious of a golden crown made for him by his metalist. Archimedes solved the issue after discovering water "displacement" principles. *(the unfortunate metalist used an alloy so the crown was not pure gold as advertised. He disappeared later that day.)
WITNESS SERVICE: Dr. Haberstroh is also available to be a professional witness at a patient's IE (IME). He will record everything, mark the time line of the exam and render a report if need be. This could dovetail with the treating doctor's original notes as well for a more comprhensive report/possible rebuttal rendered. Insurance doctors cannot refuse a witness to an insurance exam. If they do, the patient and the witness turn right around, cheerfully say goodbye and report back to the treating doctor. What the treating doctor will do is document that his patient and witness showed up at the appointed time and place, and the insurance doc was there too; but no exam was done. Give us a call. This is one of the many ways to fight the unfair IE (IME) issue.
And now, let's look at what our "friends" in the Pharmaceutical industry are up to. With "friends like these . . . . . "
GlaxoSmithKline in $3 billion fraud settlement
July 2, 2012: 12:49 PM ET
GlaxoSmithKline will pay a $3 billion settlement.
NEW YORK (CNNMoney) -- GlaxoSmithKline was slapped with a $3 billion fine Monday by the U.S. Justice Department after failing to report safety data on some of the company's most popular drugs. The payment -- with $1 billion going to settle criminal wrongdoing, and $2 billion to cover civil liabilities -- is the largest fraud settlement in U.S. history, and the largest payment ever by a drug company. And that's really saying something considering how big the fines and restitutional settlements by big Pharma have been in recent years.
GlaxoSmithKline (GSK) will plead guilty to two counts of introducing misbranded drugs, Paxil and Wellbutrin, into interstate commerce. Specifically, the government alleged that the drugs were marketed as a treatment for conditions for which they had not been approved. It said Paxil, which treats depressive and anxiety disorders in adults, was marketed to children and adolescents, and Wellbutrin, an antidepressant, was marketed as a weight-loss aid.
A third count involves a failure to report safety data about the drug Avandia, a diabetes drug, to the Food and Drug Administration between 2001and 2007.
In addition to the criminal and civil resolutions, GlaxoSmithKline has reached a 5-year compliance agreement with the Department of Health and Human Services. Under terms of the deal, according to department Inspector General Daniel R. Levinson, company executives could forfeit annual bonuses if they or their subordinates engage in significant misconduct, and sales agents are now being paid based on quality of service rather than sales targets.
GlaxoSmithKline said in a statement that the settlement will be funded through existing cash resources.
"On behalf of GSK, I want to express our regret and reiterate that we have learnt from the mistakes that were made," CEO Andrew Witty said in a statement, adding that the company has changed its procedures for compliance, marketing and selling since the incidents.
Shares of GlaxoSmithKline stock rose 1.3% in Monday trading.
JUST IN: Nov. 2011: Merck to pay nearly $1 billion to settle US Vioxx charges.
Civil charges said drug giant promoted the painkiller for unapproved use.
*Does it ever end???
JUST IN - Sept. 2011: Home Health Care MEDICARE FRAUD
Wheelchair-Bound Vietnam Vet Uncovers Multimillion Dollar Medicaid Fraud
Published September 14, 2011
TUCKERTON, N.J. - A wheelchair-bound Vietnam veteran with muscular dystrophy, from New Jersey, was enjoying his $15 million whistleblower reward Wednesday, after he uncovered a multimillion dollar medical aid fraud.
Richard West, 63, of Tuckerton, first found his Medicaid benefits were wrongly maxed out in 2004 during a visit to the dentist and spent the past seven years investigating the scam, the New York Post reported. Following the dentist visit, West returned home and examined his own records, when he found Maxim Healthcare -- the agency that provides his health aides -- had billed the government for care he never got, including visits from nurses he never met.
After spending months trying to get government officials to investigate the scam, he hired a lawyer and filed a federal lawsuit. His efforts resulted in the largest financial settlement in home healthcare fraud history.
West said, "From my wheelchair, on a ventilator and oxygen, I have spent the last seven years in this fight. Sometimes, the good guy wins. The more I uncovered, the more pissed off I got that someone was making money on my disability. It's people like me that will keep these big companies honest," he added.
Maxim -- which has 300 offices in 40 states across the US -- was found to have made $61 million from phony reimbursements. The company agreed to pay $121.5 million in reimbursements and penalties for the fake Medicaid claims and $8.4 million to the Veterans Administration. It was also fined $20 million.
West received $15 million for his efforts, as under federal law he was entitled to a percentage of the cash the company was ordered to pay back. He said he will spend his new millions on a new van, home improvements and donations to charities for the disabled.
JUST IN- Jan. 2010: More Pharmaceutical Scams -
"Drugmaker Got Kickbacks for Nursing Home Patients"
by James Ridgeway
First published in his blog Unsilent Generation yesterday, 17 January 2010
Johnson & Johnson knew that their drug, used in this way and on these patients, could actually increase the risk of death.But what's the death of a few old, disoriented, defenseless, forgotten people, compared with the potential for fantastic profits? Not much, apparently. There really should be a special place in hell for pharmaceutical manufacturers who make money by exploiting the weakest and most vulnerable of patients: old people with dementia. I wrote about one such case back in April of last year:
Pharmaceutical giant Eli Lilly recently agreed to pay a record $1.4 billion dollars to settle charges that it illegally marketed the anti-psychotic drug Zyprexa as a treatment for Alzheimer's and other forms of dementia in elderly patients. This despite the fact that the drug was not only unapproved for this "off-label" use, but had also been shown to cause obesity and diabetes.
Now, $1.4 billion might sound like a tough punishment, until you find out that Lilly's total sales of Zyprexa have topped $37 billion. And at least some of those sales were thanks to doctors who, with guidance from Lilly drug reps, wrote thousands of prescriptions for patients with virtually no ability to defend themselves.
The steep fine against Lilly apparently didn't discourage another drugmaker, Johnson & Johnson, from using even sleazier tactics to promote its own lucrative antipsychotic for use on nursing home residents. As the New York Times reported on Friday:
Johnson & Johnson paid kickbacks to the nation's largest nursing home pharmacy to increase the number of elderly patients taking the antipsychotic Risperdal and several other medications, according to a complaint filed Friday by the office of the United States attorney in Boston.
The payments violated the federal anti-kickback statute and led Omnicare, a pharmacy company specializing in dispensing drugs to nursing home residents, to submit false claims to Medicaid....The complaint charges that Johnson & Johnson and two of its subsidiaries...paid tens of millions of dollars to induce Omnicare to buy and recommend Risperdal for elderly patients as well as the drug maker's prescription pain relievers Duragesic and Ultram, and the antibiotic Levaquin.
The complaint charges that Omnicare's pharmacists engaged in intensive efforts to persuade physicians to prescribe the drugs from 1999 to 2004, a period in which the pharmacy's annual purchase of Johnson & Johnson medications nearly tripled to more than $280 million, from about $100 million. During the same period, the pharmacy's annual purchase of Risperdal rose to more than $100 million, according to the complaint filed in United States District Court in Massachusetts....
In return for Omnicare's efforts, the drug maker allegedly paid the pharmacy company kickbacks in the form of rebates based on the market share of some Johnson & Johnson drugs, sponsorship of Omnicare meetings, grants and payments for Omnicare data, like the prescribing habits of doctors, of the kind that Omnicare had previously provided the drug maker for free, the complaint said.
Let's recall that these are the same pharmaceutical companies who were praised for their cooperativeness last year when they cut a back room deal with the Obama administration to support health care reform. Part of the deal supposedly involved cutting costs for seniors on the Medicare Part D prescription drug program. Of course, it turned out the deal wasn't all it was cracked up to be-and while it supposedly "gave" to seniors with one hand, Big Pharma kept on ripping them off with the other.
In the Johnson & Johnson case, the Times reports, the company seems to have conspired to circumvent government regulations specifically meant "to protect nursing home residents from medication mismanagement, like being sedated with psychiatric drugs for the purposes of discipline or convenience." These regulations require an outside consultant pharmacist to review nursing home patients' medications once a month, and report any irregularities.
But the government's complaint in the Johnson & Johnson case raises the question of whether some companies have used the consultant pharmacists - the very people entrusted by the government with safeguarding the integrity of nursing home drug prescriptions - for corporate gain. In this case, according to the complaint, Omnicare's consultant pharmacists worked to increase Risperdal's market share....
In one company document among the court exhibits, for example, Omnicare said that its efforts generated a record market share high of 55.5 percent for Risperdal in the first quarter of 2000. "This market share represents Omnicare's ability in persuading physicians to write Risperdal in the areas of behavioral disturbances associated with dementia," the Omnicare document said.
But Risperdal, which is approved by the Food and Drug Administration to treat schizophrenia and bipolar disorder, is not specifically approved to treat behavioral problems in elderly people with dementia. In fact, in 2005 the F.D.A. required that the labels of certain antipsychotic drugs, including Risperdal, carry a black box label warning that elderly people with dementia-related psychosis treated with such drugs were at an increased risk of death compared with those taking a placebo.
So Johnson & Johnson knew that their drug, used in this way and on these patients, could actually increase the risk of death. But what's the death of a few old, disoriented, defenseless, forgotten people, compared with the potential for fantastic profits? Not much, apparently. According to the Times article:
In an Omnicare letter to Johnson & Johnson in 2001, an executive wrote that the pharmacy planned to spend about $173 million on Johnson & Johnson products.
The executive wrote in capital letters, "We are selling more high-priced drugs (read Risperdal here) for the pharmaceutical industry!!"
Also just in Jan. 2010: Boston Scientific To Pay $22 Million
Boston Scientific has agreed to pay $22 million to resolve a False Claims Act case in which its Guidant subsidiary was charged with paying kickbacks of $1,000 to $1,500 to doctors in order to get them to use their heart pacemakers. | Jan 25, 2010
Also in Jan. 2010: Novartis To Plead Guilty With $397 Million in Litigation Reserves:
Swiss drug maker Novartis has said it will plead guilty to criminal fraud charges related to the company's off-label promotion of the epilepsy drug Tripletail, and will pay a $185 million fine. Novartis' Trileptal problems are only part of the equation, however; Novartis is also being investigated for kickbacks and off-label marketing related to Diovan, Exforge, Sandostatin, Tekturna and Zelnorm. In a sign that a global settlement may be at hand, Novartis has said that it has increased its litigation reserve from $318 million to $397 million. | Jan 25, 2010
Also just in, Jan. 2010: Schering-Plough Pays $69 Million
Schering-Plough has agreed to pay $69 million to settle FCA lawsuits in which the company is charged with inflating the price of Albuterol and other drugs in order to collect millions of dollars in overpayments from California and Florida's Medicaid programs. The lawsuits were filed by Ven-A-Care of the Florida Keys on behalf of California, Florida, and the federal government, and were 11 years coming to resolution.
SEPTEMBER 2, 2009: Pfizer fined $2.3 BILLION in Health Care scam.
The U.S. Drug manufacturing giant Pfizer has agreed to pay a $2.3 BILLION penalty for illegally promoting its pharmaceutical products, the Justice Department announced today.
This agreement is the single largest health-care Fraud settlement in the history of the U.S. Justice Department.
Pharmacia and Upjohn Co., a Pfizer subsidiary, have agreed to plead guilty to misbranding the anti-inflammatory arthritis drug Bextra "with the intent to defraud or mislead," the Department stated. Bextra was pulled from the market in 2005 at the request of the Food and Drug Administration.
Dr. Haberstroh with famed forensic pathologist Henry Lee, MD and then President of the American College of Forensic Examiners, David Rosengard, MD in Orlando, Florida 2002. Dr. Rosengard passed away recently (2009). He was a internist who practiced in Boston's Chinatown area. He was a world traveler, friend of several US Presidents and a personal friend. He will be missed.
Henry Lee, MD is still best known for his work on the forensic details of the OJ Simpson Murder Trial. He has been retained to work an many high profile cases over the years.
Independent Medical Exams: Cross Examination of the Defendant's Medical/Chiropractic "Expert"
In Prince George's County, Maryland Circuit Court Judge Thomas P. Smith's article entitled "Alice in Discovery Land (A Practical Guide to Recurrent Discovery Problems)" that appeared years ago in Maryland Litigator, quoting Judge Smith's comment about the oxymoronic phrase "Independent Medical Exam."
Personal injury lawyers in accident cases on both sides of the aisle have their own unique problems. One of the big problems the insurance company's accident lawyers have is obtaining credible medical experts to testify at trial. Attorneys are in a catch-22: they need doctors who regularly testify because of the volume of cases that they (the lawyers) have; but doctors who are willing to testify have spent much of their practice testifying for insurance companies and thus, have little credibility. As a result, most of their experts are deeply wedded to the insurance companies, a fact that is rarely lost on jurors.
When the defense lawyers asks for an IME, we send out a list of conditions before agreeing to the exam. We also subpoena the doctor's records. In most cases, the doctor refused to respond to the subpoena because they do not want to reveal the extent to which they are wedded to litigation-related work generally and, specifically, to the insurance companies. Consequently, the defendant's lawyer's is forced to withdraw the expert.
A few random thoughts about cross-examining the IME doctor:
• "How much money do you make?" Studies are showing that more and more, high priced hired gun experts (even as opposed to high priced treating doctors) are being increasingly discounted by juries.
• The IME doctor usually performs only a cursory evaluation of the injury victim. This should be contrasted to the numerous examinations and conversations with the injury victim by the treating doctors. Accident lawyers should give their clients forms to fill out immediately after the evaluation that asks for, among other things, how much time the IM-doctor spent with the injury victim and what questions he asked. If the doctor did a quick review of the patient, the patient's personal injury attorney should bring this out the direct examination of the client.
• "Do you agree that there can be honest differences of opinions among doctors? Medicine is not all black and white, right?" When the IME doctor agrees -- as he/she must do -- it lends credence to the treating doctor's opinion.
• Parse the expert report. Invariably, to maintain some credibility, the IME doctor will throw you a bone or two. Cross the expert with it.
• If the treating doctor consulted other doctors in evaluating the patient, the plaintiff's accident lawyer should point out the IME doctor did not. This underscores the difference between an examination for medical purposed and an exam for an insurance company in a lawsuit.
• Often, defense experts are named before they evaluate the patient or even see a single medical record, largely because the insurance company's lawyers know they will see the case as they are paid to - the insurance company's way. The IME doctor loses a lot of credibility when the plaintiff's accident lawyer points this out to a jury.
• If the IME physician practices in the same community as the treating doctor, ask the IME doctor if he considers the treating doctor to be a well-respected physician in the community. There are no bad answers to this question.
Frank Abagnale was the featured speaker at the ACFEI Conference in Las Vegas, Oct. 2009. Dr. Haberstroh heard his lecture and got to meet Frank.
He is the subject of the popular movie, "Catch Me If You Can" and still works for the FBI to this day. Mr. Abagnale stated that while the movie had a few innacuracies, he basically quite liked it and oddly, never once spoke with Steven Speilberg about the making of the film.
Interestingly, as Frank Abagnale tells us, even in 2009 and beyond, with all the electronic means to obtain payments, make payments including rent and credit cards; the paper check is still the most popular form of payment. The demise of the paper check was predicted back in 1973 and now, it is used more than ever. Likewise, thieves are creating newer and bolder ways to pass fake checks. The Nilson Report states that check fraud losses in the U.S. come to over $20 Billion/year. This up from $5 Billion in 1993.
Considering that only 18% of banks sort their own checks and that check sorting services process 2400 checks per minute- sending checks through their machines at 400 mph (any faster and the paper would burn up), check fraud is easier than ever. Frank Abagnale has created the "Super Check" that is, not surprisingly, fraud proof, featuring a number of patented features such as: 1) Thermochromatic Ink: that reacts to changes in temperature. At 78 Degrees it begins to fade and disappears at 85 Degrees. It reappears as it cools to 78 Degrees. This reaction CANNOT be color copied and the copier heat makes it disappear. 2) Prismatic Printing: Very difficult to copy or replicate. 3) Fluorescent Ink: on the back of each Super Check is Frank Abignale's signature that is visible only under UV light to help authenticate the original document and of course, cannot be copied. There are 16 patented features in all. Frank Abagnale still consults for hundreds of busnesses and lectures regularly. Find Frank on his WEB site at: Frank Abagnale & Associates.
Not great picture of Dr. H with Frank Abagnale in Las Vegas, 2009. Tom Hanks was right; Frank's presentation is perhaps the most incredible one man show/lecture you will ever hear. Simply amazing.
Junk IME Science:
No or low property damage = no injury
Insurance companies will use any excuse to keep insurance premiums and profits.
1) State Farm's use of paper reviews to deny medical
payments claims : *Paper Review: looking at a case file only, not the actual patient. AKA: "Peer Review."
Dateline, a syndicated television show, on June 23, 2000, revealed the results of a 15 month investigation of a paper review of medical payments claims by State Farm. This one hour presentation revealed that State Farm and all big automobile insurance companies used paper review companies like Comprehensive Medical Review (CMR) in San Diego, California that had produced 27,000 reports over the past 15 years for State Farm and many of the nation's the leading insurance companies.
The investigation revealed that the reports were written by CMR employees with no medical training who used 160 stock computer paragraphs that were slanted to deny medical payments benefits to State Farm insured's. The doctor on staff would look at and sign 50 medical reports in one hour, about 1 per minute. Also, that State Farm adjusters would call CMR to help author the medical reports to reduce the amount of money paid on the claim.
An economist hired by a person suing State Farm analyzed nearly 100 claims State Farm sent to CMR that proved how paper reviews profit State Farm. He found that accident victims on average had about $ 7,400 in medical bills. CMR's paper review recommended slashing those claims. In the end, State Farm paid on average only $ 4,400, saving State Farm about $ 3,000 in medical bills every time it used a paper review.
Based on the above information, if State Farm saved about $ 3,000 per medical payments claim by using CMR, then, 27,000 reports during a 15 years period times $ 3,000 equals about $ 81,000,000.00 profit to State Farm by cutting medical payment benefit that were owed to their insured's.
2) Deliberate fraud by State Farm in repair of insured's vehicles :
In 1999, an Illinois jury awarded a $ 456 million dollar judgment against State Farm and the Judge Speroni added another $ 730 million dollars because the company deliberately defrauded policyholders by requiring body shops to use inferior crash parts to repair their wrecked vehicles. The combined award totaled $ 1.18 billion dollars.
During the trial, evidence proved that State Farm used inferior crash parts for 11 years. State Farm testified that in 1997 alone, such parts saved its customers $ 237 million dollars. If we multiple $ 237 million times 11 years, State Farm defrauded its customers and made a profit of 2.6 billion dollars by forcing body shops to buy inferior crash parts instead of original equipment manufactured parts to repair policyholder vehicles.
3) Junk science, no or low property damage = no injury:
Prologue: the beginning of a scam:
Prior to 1980, a minor collision could cost an insurance company thousands of dollars to repair a 5 MPH rear-end property damage loss. For a few vehicles, the cost to repair a vehicle in a 5 MPH collision as of 2000 had not changed much. A series of studies by the Insurance Institute of Highway Safety  reported in the year 2000, showed that many vehicles with the new energy absorption bumpers showed no damage or less than $ 500 damage but a few had thousands of dollars of property damage at 5 MPH. For example, a mid-size utility Mitsubishi Montero had $ 2,609 in property damage in a low speed crash rear-end crash at 5 MPH into a flat barrier.
To save billions of dollars in property damage repair costs in low speed automobile collisions, the insurance lobby in Washington DC was instrumental in persuading the National Highway Traffic Administration (NTHSA) to implement the "No damage" 5 MPH Bumper Standard Part 581 in 1980  forcing car manufacturers to design "No damage" bumpers in low speed collisions. In 1983, the 5 MPH standard was reduced to 2 ½ MPH.  *See our "Automobile Accidents" page.
Creation of the scam:
Between 1980 and 1990, the insurance industry saved billions of dollars in repair costs because they influenced NTHSA to pass the no damage bumper for low speed collisions. The industry knew that low speed property repair costs were expensive and for some vehicles cost thousands of dollars to repair prior to 1980. Remember, this energy absorbing bumper mania, which we are all used to now, was designed to save MONEY for the insurance industry, NOT provide protection for the occupants of a car.
By 1990, the financial issue became, "How do we save money on claims of whiplash injury in low speed collisions. " Prior to 1980, photographs of property damage would show substantial property damage in low speed auto collision and evidence of property damage was consistent with claims of whiplash injury. Evenually, someone in the insurance industry realized that if a photograph of the front or rear bumper of the car showed little to no property damage, the insurance company and its legion of defense lawyers could argue, "No property damage MUST mean no injury." This is also known as the "No Crash, No Cash" defense strategy. It plays well with juries. Think about it; if the car that was in the accident "looks" OK, then juries automatically assume the people INSIDE the car must be OK too.
This is the basis of the scam. The insurance industry knew that the amount of force is the same in a low speed impact prior to 1980 and after the implementation of the "No damage" bumper. The only difference now is that the property damage is virtually non-existent after 1980; that is to say, cars don't "look" damaged like they used to. *energy is still transferred from the "bullet" car into the "target" car and people are getting hurt that ever before. Again, it's just that the damaged car doesn't look damaged these days.
Proof that "No property damage, no injury" is a scam:
The insurance industry routinely hires defense bio-mechanical experts to contest minor impact soft tissue injuries. (MIST) The basis of this defense strategy is based on no/low property damage to the vehicles. In fact, Accident Reconstructionists (AR) are the big rage now in the new millenium. Their papers look good with many official looking calulations and official sounding conclusions. The facts are: i) AR reports are merely "after the fact" guess work at best, ii) Doctors and plaintiff's lawyers don't rebut these ARs because they don't know how to, iii) thus leading to the AR's reports becoming essentially the final word in case management.
The Brault study , a low speed human crash study, has refuted every basis of the the defense strategy of no property damage, no injury. Forty-two persons were exposed to rear-end impacts speed changes of 2.5 mph and 5 mph. Objective clinical deficits were consistent with whiplash associated disorders (WAD), were measured in men and women at 2.5 mph and 5 mph. The test vehicles were hit in the rear over one hundred times without any property damage. After impact, with no braking, the force of the impacts caused the vehicles to roll forward 3 meters into a gravel pit before stopping. 
A study quoted in the Brault Study, Ryan and coworkers, found that automobile occupants who were unaware of the impending collision were 15 times more likely to have persisting WAD 6 months post impact. The Brault study participants were hurt even though they knew of the impending collision. If an injury victim is unaware, his neck muscles are not tense, the impact causes a 10 lb head to be snapped backwards within a tenth of a second at a force of 6.7 to 12'g's of force. . This necessarily means that a 10 lb head is loaded with a force comparable to 67 lbs to 120 lbs within a tenth of a second. This is why injury victims get hurt in a rear end, no property damage collision.
Plaintiff attorneys throughout California are starting to file motions in limine or making a request for a Kelly-Frye hearing to exclude the defense bio-mechanical testimony based on junk science that no property damage proves no injury. Courts throughout California and our nation are routinely excluding this junk science testimony.
1. The Paper Chase by Dateline NBC New, televised June 23, 2000.
2. Los Angeles Times news story, October 9, 1999.
3. Insurance Institute for Highway Safety crash tests reported May 24, 2000.
4. National Traffic Highway Safety Administration Standard Part 581, 1980.
5. National Traffic Highway Safety Administration Standard Part 581, 1983.
6. Clinical Response of Human Subjects to Rear-End Automobile Collisions, 1998.
7. Head/neck Kinematic Response of Human Subjects in Low-Speed Rear-End Collisions.
Dr. Haberstroh with famed FBI Forensic Investigator and co-founder of the "Behavioral Sciences" department at the Bureau, John Douglas at the Hotel Del, Coranado, California, 1995. Mr. Douglas was a past President of the American College of Forensic Examiners and has been a key figure in the virtual revival of interest in forensics in general. He lectures frequently and is still an occasional guest lecturer at the ACFE annual conventions.
MERCK PAYS RECORD FRAUD FINE
PHILADELPHIA/Feb. 7, 2008 - Merck and Co. has agreed to pay $671 million to settle claims that it overcharged Medicaid programs for four drugs, including Vioxx and Zocor, and to resolve allegations of improper marketing to doctors, U.S. prosecutors and company officials announced Thursday.
In a case in Philadelphia, Merck agreed to pay $399 million plus interest for improper calculation of Medicaid rebates and its marketing practices. In a Louisiana case, it agreed to pay $250 million plus interest for its rebate practices. The interest payments boost the total payout to $671 million, Merck said. Drug companies are required to report to the government the lowest price for its product to ensure that Medicaid programs get the benefit of the same discount. Merck, however, was hiding the steep discounts it gave to hospitals by reporting higher prices to the government, prosecutors said.
From 1997 to 2001, Merck also gave money and perks to doctors and other health care professionals to entice them to prescribe Merck drugs, a practice the government called excessive. Merck said the settlements do not constitute an admission of any liability or wrongdoing. The Louisiana case involved pricing for the heartburn drug Pepcid when it was sold only with a prescription. The Philadelphia case, which involved a related Nevada action, involved pricing programs for the cholesterol drugs Zocor and Mevacor and the painkiller Vioxx, which was pulled from the market in September 2004.
"What we have here is a disagreement (over) the rules of the Medicaid rebate program," said Merck spokesman Ronald Rogers. "These civil settlements were the best and most appropriate way to resolve these lengthy investigations and bring these matters to closure."
"At the time that these pricing programs were in place, Merck believes that it acted in good faith and complied with the regulations that were in place at the time," he said.
When Merck reported its fourth-quarter financial results on Jan. 30, they included a $671 million charge for the anticipated resolution of federal and state civil probes into past sales and marketing practices.
"The company has been working with federal and state authorities and has been making progress toward definitive agreements" to resolve the matters, the earnings report stated.
U.S. Attorney Patrick Meehan was joined at a news conference by officials with the Department Of Health and Human Services Office of the Inspector General and representatives from the state Attorneys General in Delaware, Illinois, Massachusetts and Nevada. Merck shares fell 2 cents to $45.69 in midday trading Thursday.
Dr. Haberstroh with famed attorney and veteran of the OJ Simpson trial, Barry Scheck; San Diego, 2006. Attorney Scheck is considered the leading legal expert in forensic DNA testing. Along with his law school partner, he is the founder of the Innocence Project which has exonerated nearly 200 convicted individuals either sitting on death row or serving life sentances, based on DNA testing after the fact.
DNAtesting has been continually refined with far less false positive results since the OJ trial. It is now one of the leading tools in law enforcement to either proove guilt or establish innocence. If you've ever watched CSI for a few shows, you will see a propondeance of DNA gathering and subsequent testing of those samples to narrow a suspect list. In any event, Attorney Scheck has been the leader in prooving the innocence of wrongly convicted individuals for close to two decades as of 2009.
DEPARTMENT OF JUSTICE-UNITED STATES OF AMERICA
FOR IMMEDIATE RELEASE
THURSDAY, JUNE 26, 2003
TDD (202) 514-1888
LARGEST HEALTH CARE FRAUD CASE IN U.S. HISTORY SETTLED HCA INVESTIGATION NETSRECORD TOTAL OF $1.7 BILLION
WASHINGTON, D.C. - HCA Inc. (formerly known as Columbia/HCA and HCA - The Healthcare Company) has agreed to pay the United States $631 million in civil penalties and damages arising from false claims the government alleged it submitted to Medicare and other federal health programs, the Justice Department announced today.
This settlement marks the conclusion of the most comprehensive health care fraud investigation ever undertaken by the Justice Department, working with the Departments of Health and Human Services and Defense, the Office of Personnel Management and the states. The settlement announced today resolves HCA's civil liability for false claims resulting from a variety of allegedly unlawful practices, including cost report fraud and the payment of kickbacks to physicians.
Previously, on December 14, 2000, HCA subsidiaries pled guilty to substantial criminal conduct and paid more than $840 million in criminal fines, civil restitution and penalties. Combined with today's separate administrative settlement with the Centers for Medicare & Medicaid Services (CMS), under which HCA will pay an additional $250 million to resolve overpayment claims arising from certain of its cost reporting practices, the government will have recovered $1.7 billion from HCA, by far the largest recovery ever reached by the government in a health care fraud investigation.
"Health care providers and professionals hold a public trust, and when that trust is violated by fraud and abuse of program funds, and by the payment of kickbacks to the physicians on whom patients and the programs rely for uncompromised medical judgment, health care for all Americans suffers," Robert D. McCallum, Jr., Assistant Attorney General for the Civil Division said. "This settlement brings to a close the largest multi-agency investigation of a health care provider that the United States government has ever undertaken and demonstrates the Department of Justice's ongoing resolve and commitment to pursue all types of fraud on American taxpayers, and health care program beneficiaries."
"Let this case be a continuing reminder to all that in the fight against health care fraud this office will not be deterred," said Acting Principal Deputy Inspector General Dara Corrigan. "Medicare dollars paid to provide ever more expensive health care services to the country's taxpayers should never be fraudulently diverted. This is our job and our trust and we take these duties very seriously," Corrigan concluded.
This latest settlement resolves fraud allegations against HCA and HCA hospitals in nine False Claims Act qui tam or whistleblower lawsuits pending in federal court in the District of Columbia. Under the federal False Claims Act, private individuals may file suit on behalf of the United States and, if the case is successful, may recover a share of the proceeds for their efforts. Under the settlement, the whistleblowers will receive a combined share of $151,591,500, the highest combined qui tam award ever paid out by the government.
"We are grateful for the assistance given by the whistleblowers over the course of the past nine years of investigation and litigation," McCallum said. "And we are proud of the work of government personnel as well as counsel for the whistleblowers, who together pursued these matters through investigation and strenuous litigation. This result demonstrates the commitment of the Department to the qui tam statute and that the statute works as Congress intended."
Under the first of three agreements announced today, which becomes effective upon the court's dismissal of the lawsuits, HCA will pay nearly $620 million to resolve eight whistleblower lawsuits in which the government had intervened alleging that HCA systematically defrauded Medicare, Medicaid and other federally funded health care programs through schemes dating back to the late 1980s. HCA will pay an additional $11 million to resolve separate allegations of improper HCA billing practices.
The settlement requires HCA to pay:
$356 million to resolve whistleblower lawsuits alleging that HCA engaged in a series of schemes to defraud Medicare, Medicaid and TRICARE, the military's health care program, through hospital cost reports, the year end claims submitted by hospitals to the government to reconcile payments received throughout the year with amounts they claim are actually owed. In 2001, a subsidiary of Nashville-based HCA, Columbia Management Companies, Inc., pled guilty in the Middle District of Florida to related charges on eight counts of making false statements to the United States and paid $22.6 million in criminal fines. An additional amount of $20 million of the settlement is being paid toward a resolution of cost reporting fraud allegations pursued separately by James Alderson and John Schilling, the relators who filed the lawsuits. In total, the two relators are to receive a total of $100 million as their statutory share of the settlement.
$225.5 million to resolve lawsuits alleging that HCA hospitals and home health agencies unlawfully billed Medicare, Medicaid and TRICARE for claims generated by the payment of kickbacks and other illegal remuneration to physicians in exchange for referral of patients. In 2001, Columbia Management Companies, Inc., pled guilty to one count of conspiracy to pay kickbacks and other monetary benefits to doctors in violation of the Medicare Antikickback Statute and paid a $30 million criminal fine. Dr. James Thompson, a doctor who filed suit against the company in 1995, will receive $41.5 million as his statutory share of the settlement. Gary King, a former HCA employee, will receive $5 million and Ann Mroz, a former HCA nurse, will receive a share of $837,500.
$17 million to resolve allegations that certain company-owned hospitals billed Medicare for unallowable costs incurred by a contractor that operated HCA wound care centers, and for a non-covered drug that the contractor manufactured and sold to hospital patients. The 2001 Columbia Management Companies' guilty plea concerning cost report fraud included a charge related to wound care center costs. HCA's wound care center management contractor, Curative Healthcare Services, Inc., previously paid $16.5 million to resolve related allegations pending at one time in these same lawsuits. Joseph "Mickey" Parslow, a former HCA financial officer, will receive $2,990,000 and Francesco Lanni, a former Reimbursement Manager at the Wound Care Center at New York Methodist Hospital in Brooklyn, New York, will receive a share of $680,000.
$5 million to resolve allegations concerning the transfer of patients from HCA facilities to other facilities and the claiming of excessive costs for those transfers.
$5 million to resolve allegations that HCA's Lawnwood Regional Medical Center in Fort Pierce, Florida submitted false claims in Medicare cost reports by inflating its entitlement to funds to treat indigent patients and by shifting employee salary costs in order to increase its reimbursement from the federal health care program.
$950,000 to settle allegations made by Michael Marine that HCA improperly shifted its home office costs to hospitals. Marine will receive a share of $116,500.
Today's settlement agreement incorporates the terms of a Corporate Integrity Agreement executed by HCA and the Office of the Inspector General, Department of Health and Human Services in December 2000 that obligated the company to engage in significant and comprehensive compliance efforts into 2009.
In a separate agreement, HCA agreed to pay $1.5 million to resolve allegations that an Atlanta, Georgia hospital, West Paces Medical Center, paid kickbacks for the referral of diabetes patients. Those allegations had been pursued since 1996 by a whistleblower in a case in which the United States had declined to intervene, captioned U.S. ex rel. Pogue v. American Healthcorp, Inc. et al.. Pogue, a former employee of a co-defendant in the case, Diabetes Treatment Centers of America, will receive a share of $405,000 from the HCA settlement. Pogue continues to litigate claims against his former employer and a group of Atlanta physicians.
Additionally, a state negotiating team appointed by the National Association of Medicaid Fraud Control Units has reached agreement with HCA to resolve related issues with affected state Medicaid plans for $17.5 million, representing direct state losses. The terms of that agreement are being finalized by the parties and are not part of today's settlement.
Today's administrative agreement between HCA and CMS will require HCA to pay CMS $250 million in order to resolve claims they maintained against each other arising from HCA's hospital cost reports and home office cost statements for cost reporting periods ending July 31, 2001. These claims resulted from HCA cost reports that were not processed since 1997 as a result of the government's investigation.
Be advised; chiropractors are still ranked as amongst the most trustworthy, patient friendly practitioners in public practice. While a couple have been caught in fraudulent activities, the overwhelming percentage of DCs carry on in an ethical, professional manner. In my ongoing series of articles and bulletins regarding fraud, let's also consider what happens at hospitals. Did you know since 1995, about 1/3 of all hospitals in America have gone bankrupt? The expenses and overhead at any kind of hospital is staggering, thus forcing them either out of business or into the "overcharge" mentality. According to Bankrate.com, "profit hungry hospitals are overcharging consumers an estimated $10 Billion/year. Some facilities deliberately work to keep bills indecipherable. " As a forensic examiner, I urge all of you reading this, to examine your bills from whomever you encounter medically, but especially hosptials. One of my favorites is the "Mucous Retrieval System." This is a coded item often found on a person's hospital bill. Known more commonly as a box of kleenex, this little item usually gets billed out at $129 per unit. Of course, we all know you can buy a box of kleenex or a generic equivalent for around $4 at Stop & Shop. I urge you to ask FIRST, BEFORE your hospital stay, what is included in the room charges. Towels, oops, I mean "manual sanitary applications," go for $50 APIECE. So check and if need be, bring in your own towels and kleenex. In an article by Steven Malanga in the "City Journal" Spring/2006 issue entitled "How to Stop Medicaid Fraud," The author points out the ugly truth regarding one major problem with the total health care tab in the United States. He tells us that experts now grimly estimate that abuses in Medicaid eat up at least 10% of the program's total budget nationwide. That comes to $30 BILLION a year. That fraud figure is about 3 times greater than all the legitimate billing of all chiropractors in the entire U.S. (see Dept. of Commerce-US) The scams by hospitals and their doctors are endless: doctors billing for over 24 hours/day of procedures, phony medical companies billing for phony services, pharmacists filling prescriptions for dead patients, "home" health care companies demanding payment for treating patients who are actually still in the hospital . . .or dead, random overcharges for items or services never rendered and the rip-offs go on seemingly endlessly. http://www.sj-r.com/sections/news/stories/93248.asp *talks about hospital fraud.
MEDICAID: Was created on July 30, 1965 as part of President Lyndon Johnson's so-called "Great Society" plan through Title XIX of the Social Security Act. Each state monitors this program which is funded both Federally and at the State level. Thus, Medicaid is a social welfare program. Johnson envisioned a socialist state where the government took care of everyone. Of course, the people who actually work for a living would need to be taxed into oblivion to fully pay for such a vision. Costing $1 Billion in 1965, the program skyrocketed in cost to $6.3 Billion by 1970 and then to $18 Billion by 1977. The system is now standing at a about $300 Billion/year. Medicaid in California is the single biggest item on the state budget, surpassing even education. It gobbles up over 25% of the Florida budget and over 30% of the Rhode Island state budget. Federal and state supervision of this program and its sister operation Medicare is negligible. No real surprise then, when we hear about more and more medicaid fraud. In one brazen scheme, a group of Nigerian immigrants set up a network of fake medical supply stores in the Southwest hoping to swindle Medicaid and Medicare. They then paid off local doctors to write scripts for motorized wheelchairs worth $7500 per chair. What happened was that the Nigerians actually gave patients $1500 motor scooters, pocketing the difference. Investigators finally shut down the operation after noticing billings for excess wheelchairs in Arizona, Texas and other states totalling in the mind numbing hundreds of millions. Most of it lost forever, stolen by a savvy team of immigrants. Patient transportation services is another field so lucrative and so loosely regulated and watched that it draws Medicaid cheats like flies. One Virginia firm founded to allegedly transport patients instead stole the patient's indentities and began billing for extra services it never rendered. This happend also in New York where an ambulance service overbilled for over $300 Million. Haven't you all noticed the absolute proliferation of "ambulance" services in the last decade? The money is staggering. One Brooklyn dentist overbilled for so much that finally the New York Times exposed her, not Federal investigators, when it became known she was the biggest dentist in New York State-this only one year after graduation. You get the idea. Please scrutinize your bills when you get them and look for overbilling. If it is a relatively small item, call your doctor or hospital and inquire as to whether or not there was a mistake. If the item seems ridiculous, it probably is and you should probably call the authorities.
MEDICARE: Was originally proposed in 1945 by President Harry Truman in this early attempt to offer a socialized national health care plan. On July 30, 1965 Medicare along with its companion program Medicaid was signed into law by President Lyndon Johnson. Interestingly, former President Harry Truman was the first person in the U.S. to enroll in Medicare. Over the course of time, more and more benefits have been added to this Federally funded program. Thus, it is an "entitlement" program as opposed to the welfare giveaway that is Medicaid. Nevertheless, it has been estimated by the CMS (Centers for Medicare and Medicaid Services) that fraud is rampant in Medicare as it is in Medicaid, to a similar amount-around $30 Billion/year.
FEMA: 6/14/06: Did you hear about Hurricane relief money?? An audit found $1.4 Billion in bogus claims of damage. And it was already paid!
Practitioners: We've heard alot about individual doctors and hosptials, but what about insurance companies themselves? Feel free to access the links listed below. You may (or may not) be surprised to hear about what the insurance companies themselves are up to:
Allstate Accused of Cheating Claimants
Investigation Reveals Widespread Corruption in Insurance Industry
http://www.capweb.net/index/Articles/Insurance/Insurance+Fraud *Insurance company FRAUD
http://www.consumeraffairs.com/news04/2006/07/il_liberty_mutual.html *Liberty Mutual Ins. FRAUD
http://www.demutualization.org/2005/12/metlife-demutualization-securities_16.html *MetLife FRAUD
Failed Back Syndrome: The Disturbing Statistics: Presented at DG DISPATCH - AAPM *Too many un-necessary back surgeries
http://chicagobusiness.com/cgi-bin/news.pl?id=21245&rel=1 *More on Liberty Mutual
Doctors (medical) are the third leading cause of death in the U.S. at 225,000 per year. *Self explantory, re-MDs
*Doctors settle Class Action Against N.J.'s largest HMO! Find this article at http://www.claimsguides.com/news/east/2006/10/17/73372.htm
Struggling TUFTS Health plans layoffs: Boston Globe, 10/12/06
Drug reactions send 700,000 people to th ER every year~! Find this article at JAMA: http://jama.ama-assn.org
Skyrocketing Health Costs
Another Article confirming the unsubtatiated nature of CABS (Coronary Artery Bypass Surgery)
Volume 10 Number 19
Wednesday, September 27, 2006
False Claims Act (FCA)
Most Recoveries From Qui Tam Actions
Come From Health Care Industry, DOJ Says
Nearly 80 percent of the $1.4 billion the federal government recovered from False Claims Act qui tam actions in 2005 came from health care fraud, an official with the Department of Justice told the Taxpayers Against Fraud Education Fund Conference in Washington Sept. 12. Joyce R. Branda, deputy director of the fraud section in DOJ Civil Division's Commercial Litigation Branch, said that $1.1 billion of that year's recovery, representing 79 percent of the total, came from fraud in the health care industry. She said that from 1986 through 2005, the United States recovered more than $9.6 billion from FCA qui tam actions. As a result of those recoveries, whistleblowers received shares of more than $1.6 billion. During that period, recoveries from qui tam actions and nonqui tam actions totaled more than $15 billion.
>U.S. Attorney for the District of Massachusetts Michael J. Sullivan said in fiscal 2006, DOJ recovered more than $2.3 billion in just three settlements, making this year the most effective year for recoveries. "Every dollar spent by the government returns more than $15 in FCA recoveries," Sullivan said. "Of the $3 billion Massachusetts recovered from health care fraud in the last five years, $1 billion was recovered in the last year alone."
Dr. H Notes: The bulk of this fraud recovery was from big pharmaceuticals and other large corporate entities. Repeated efforts to speak with staff at Mr. Sullivan's office have not produced any results. Thus, a breakdown of exactly who paid what in restitution and recovery is not clear despite repeated inquiries by me.
Blurb from the BOARD WEB site: "The Division of Professional Licensure is an agency within the Office of Consumer Affairs and Business Regulation. It is responsible for ensuring the integrity of the licensing process for 43 trades and professions regulated by 29 boards of registration, the updating and renewal of approximately 330,000 licenses and the maintenance of databases for licensing, enforcement and revenue collection. In Fiscal Year 2005, the Division of Professional Licensure imposed record levels of enforcement, including 1,186 disciplinary actions, $173,850 in fines and returned more than $53,000 in refunds to consumers."
Thus, from available sources including the Board WEB site itself (see above) whose most recent figures reveal $226,850 collected in fines and refunds from 29 Different BOARDS, Chiropractic accounts for a tiny fraction of the money recovered by any means. This clearly shows that Chiropractic is NOT the problem in health care fraud issues.
U.S. Recovers $5.7 Billion in Healthcare Fraud in Five Years
The federal government recovered $5.7 billion from civil healthcare fraud cases from 1999 through 2003, according to a report released April 22 by the Economic and Social Research Institute. The federal government recovered $13 for every dollar it spent pursuing healthcare fraud, the study said. In 2003, $1.65 billion was recovered, an increase of 38% over 2001 and more than double the 2000 total. The report said many of the cases involved violations of the federal False Claims Act. For more information, go to www.taf.org/meyerpr.pdf. Again, the vast bulk of this recovery came from big pharmaceuticals. Most of that can be traced to drug companies selling drugs that don't work. Often, MDs are bribed to start using a particular drug with their patients and other such scams.
(Source: The National Journal Group)
Arizona bars IMEs from Chiropractic board of Examiners
WCA assists state group in passing model legislation
A chiropractic board taken over by IME orthopedic-and medically oriented DCs determined to drive subluxation‑based chiropractors out of business. Chiropractors whose careers have been destroyed because they forgot to initial their progress notes on one visit or used CPT code 99203 instead of 99202. This is the current scenario in Arizona, according to many insiders who say the nightmare began when Dianne Haydon, DC, was appointed as one of three licensed chiropractors serving on the Arizona Chiropractic Board of Examiners on July 1, 2003.
Dr. Haydon's resume notes that from 1991 to the present, she has been involved in "chiropractic consulting, claims review and independent chiropractic evaluations." Such terms normally mean working for insurance companies to deny claims. The situation came to an explosive head on July 1, 2004, when the second IME was appointed to the board. This time, the post was given to Steven Baker, DC, well known for many years in Tucson as a pro-insurance IME doctor. Now, two of the three DC board members had direct ties to the insurance industry.
Critics began a careful examination of the board's activities and found that 80% of all complaints filed with the board came from insurance companies. Doctors throughout the state began connecting the dots and came to the inevitable conclusion that the state's board was dominated by doctors whose income was, at least in great part, dependent upon their relationship with insurance companies. These same doctors were hearing complaints against DCs filed by these companies, giving rise to accusations of conflicts of interest. In response, the Arizona Chiropractic Society (ACS), led by Alan M. Immerman, DC, successfully pushed for legislation in 2006 to prohibit board members from concurrently working for insurance companies as IME doctors and serving on the board. The law is believed to be the only one of its kind in the country. The group's investigation uncovered that the Arizona CBE spent $20,000 in an attempt to defeat this law -- a move seen by some as an effort to protect the incomes of Haydon and Baker.
"The tale in Arizona is just another tragic account of a chiropractic board gone wrong, a board that has lost its sense of direction, forgotten its basic mission, and determined that it is going to turn the profession into a sea of medipractors," Dr. Immerman stated. Aiding and supporting the ACS in its efforts was the World Chiropractic Alliance (WCA), whose president, Terry A. Rondberg, DC, practiced in the state for many years. "I have strong ties to Arizona and am well aware of the problems that have existed in its board," Dr. Rondberg stated. "For years, I battled the blatantly anti‑subluxation‑based chiropractic attitudes of the medically oriented DCs on the board. This latest challenge is equally dangerous."
It was partly because of these biased attitudes that Rondberg and Immerman formed a state organization based on the principle of "live and let live," and then founded the World Chiropractic Alliance to promote that concept to the international chiropractic community. Rondberg stated that, for the WCA, Arizona was in many ways a test case. "We need to clean the insurance industry reps out of our boards," he explained. "Doctors who work as IMEs to help cut claims for insurance companies have no business regulating our profession or passing judgment on doctors." The WCA is also working to monitor similar situations in other states and has provided assistance in exposing and fighting abuses and discrimination by boards throughout the country. Based on a statistical analysis from the National Practitioners Data Bank, the Arizona Board is among the most active in taking disciplinary action against doctors (the other 'most active' states are California, Colorado, Florida, Illinois, Michigan, Pennsylvania and Texas).
In a sample time period reviewed by the ACS, Arizona had 272 "adverse action reports" while its neighboring state New Mexico had only one; Utah, 28; Nevada, 12; and Wyoming, 1. By early 2006, the problem with the Arizona Board had clearly reached a crisis point. Scores of doctors in Arizona had been harshly disciplined for what most observers deemed very minor violations. Subluxation-based doctors found that their record keeping methods almost always resulted in their being found guilty of "unprofessional or dishonorable conduct of a character likely to deceive or defraud the public or tending to discredit the profession." The statement of guilt is placed in the doctor's file online for the public and reported electronically to the National Practitioners Data Bank, which forwards the information to all PPOs and HMOs. The doctors suffer extreme personal and professional damage and are normally not allowed to participate in any managed health plans. Ultimately, they can suffer loss of new patients and even the destruction of their practices, careers, and, in some cases, families and health. Many doctors have become so intimidated by the board and the ever-present threat of insurance company complaints, they have reportedly turned away patients needing chiropractic care if they felt there was any possibility of their claims being unjustly audited. ACS members, including Immerman, increased their surveillance of the board, attending meetings and filing reports with their organization that were published in the monthly ACS News. The publicity helped raise awareness that the problem was widespread and being combated by the ACS. Other doctors started stepping forward to share stories of their own experiences with the board. In July 2006, ACS received a large packet containing an anonymous complaint filed with the Arizona Ombudsman's Citizen's Aide Office, an agency charged with mediating disputes between citizens and state entities.
The 70-page complaint gave extensive details documenting the Arizona Board's use of intimidation, humiliation, condescension, sarcasm and unprofessional conduct directed at chiropractors who appeared before it. It also uncovered instances of enforcement of standards of care that do not exist; unequal application of the law (such as one doctor receiving severe penalties for certain violations while another doctor received minimal sanctions for the same violations); arbitrary interpretation of the law (for example, requiring chiropractors to note time parameters and location of physiotherapy modalities, when this is not required by rule or law); excessive and unjustified reprimanding of chiropractors; and failing to conform to the intent of the Chiropractic Act, by imposing severe sanctions for minor record keeping violations when the chiropractor has done nothing to jeopardize the health, welfare and safety of the patient or the public. ACS re-filed the complaint with the Ombudsman and asked to be added as an official co-complainant. The investigation is still underway at this time. A key area of concern revolves around the fact that the Arizona Chiropractic Board can discipline a doctor for failure to comply with "recognized standards in chiropractic." In 1995, the Arizona Association of Chiropractic (AAC), successfully lobbied for a mandatory continuing education bill that gave the board the power to establish and enforce clinical standards of practice. The AAC has an office across the hallway from the board and is seen as an ally of the board, not a watchdog of the board as is the ACS. Both Haydon and Baker are AAC members. However, the board never defined what it means by "recognized standards." In reality, critics claim, the "standards" are set by board members in an arbitrary and capricious manner and can vary from one case to the next, from one meeting to the next. Rather than reflecting generally accepted chiropractic practice, they reflect the views and preferences of the board members. Since two of the three DCs on the board have been long-time defense pro-insurance oriented IME doctors with extensive orthopedic training, this has been seen as particularly threatening to subluxation-centered practitioners. "The board's vision clearly is to turn the profession into a sea of medipractors," Immerman stated. "Only ACS stands in their way. ACS has tried to get the legislature to remove reference to 'recognized standards' from the law since it is undefined and probably indefinable in chiropractic, but the AAC has objected. Sadly, the AAC supports having orthopedic pro-insurance IME DCs on the board force their standards down the throats of all state DCs."
Calif. governor steps in to clean up Chiropractic licensing board
After months of turmoil and complaints from state and national organizations, Calif. Gov. Arnold Schwarzenegger stepped in to begin re organizing the Board of Chiropractic Examiners. The Governor's actions were the first step in ending the bureaucratic staff corruption that plagued the embattled Board.
The situation was brought to light by a series of complaints against Board staff members filed by the World Chiropractic Alliance (WCA) as well as the California Chiropractic Association and the International Chiropractors Association of California. Numerous complaints were directed at Maggie Craw, a paid consultant to the Board who was accused of overstepping her authority to harass certain doctors of chiropractic. An independent investigation, commissioned by the WCA, revealed that Craw had abused her position by singling out chiropractors based on her own personal and professional biases. In particular, it was disclosed that Craw targeted chiropractors who hold that the purpose of chiropractic is to detect and correct vertebral subluxations, misalignments in the spine that interfere with normal nerve transmission through the body. Recent research has indicated that subluxations have detrimental effects on health and may be linked to a variety of health conditions.
The WCA investigative report also revealed that Craw had been concurrently employed by an insurance company that reviewed claims submitted by chiropractors. Craw in her capacity as a consultant for the Board could then order those doctors to be investigated by the Board. The disclosure of this conflict infuriated the chiropractic community and led to outcries for her removal. The new Board immediately launched its own investigation of Craw.
"There was definitely an anti chiropractic bias among certain members of the Board's staff," stated Terry A. Rondberg, DC, president of the WCA. "For instance, it was learned that Dr. Craw was a member of a fringe group that has publicly denied the validity of subluxation based chiropractic, which is the foundation for the entire profession. To have someone like that running a licensing board hurts the profession and denies the public access to a valid health alternative."
The WCA submitted several formal complaints and worked with prominent state leaders to expose the problems plaguing the Board. Its efforts were instrumental in convincing Gov. Schwarzenegger to step in and appoint new members to the Board that would restore public confidence to the agency. The new Board met on March 1 to start the housecleaning by firing Catherine Hayes, the Board's executive director.
"California is fortunate to have a governor who understands the health care needs of its citizens," Dr. Rondberg stated. "He's widely recognized for his commitment to health care and chose highly qualified individuals recognized for their chiropractic expertise as well as their integrity."
Some newspaper articles implied that the main complaint against the Board was that it over regulated the chiropractic profession. Dr. Rondberg denied this, saying that the Board didn't over regulate the profession, but applied existing regulations in an arbitrary and biased manner. "The Board was, in essence, being run by two or three rogue staff members, who took actions without the knowledge or consent of the Board members," he explained. "These staff members were abusing their authority by singling out doctors who chose to offer subluxation based chiropractic to their patients. This didn't fit into the view of chiropractic held by members of Board's staff, so they were repeatedly harassed and threatened."
Complaints filed by the World Chiropractic Alliance against Dr. Craw chronicled several specific cases in which complaints were filed by Board staff members against doctors despite a lack of evidence of any wrongdoing. Ultimately, the WCA commissioned San Juan Capistrano attorney Carlos F. Negrete to complete an investigation and report, which he and Dr. Rondberg presented to the Board.
Soon after the WCA filed its complaints, numerous California doctors came forward to corroborate the accusations. One stated that Dr. Craw appeared to be a "power drunk bureaucrat, in over her head and enforcing her whim rather than thoughtfully using the law to protect the people of California and improve the profession." Another noted that she "enjoys employing Draconian measures to intimidate her own profession rather than doing what her profession has paid her to do: investigate and assess fairly the charges made against chiropractors."
Dr. Rondberg commented, "It was obvious that the Board was in disarray and not serving its rightful function to protect the people of California by overseeing the chiropractic profession in a fair and responsible manner. For the Governor to step in and correct the situations was a bold and courageous move that demonstrates his dedication to providing the best possible health care to the people of this state."
Rondberg gave much of the credit for the changes to Negrete, who represented the World Chiropractic Alliance and oversaw the complaint process. Negrete is a well known health care rights attorney and the only lawyer in America who has defeated the notorious anti chiropractic leader Stephen Barrett and his "Quackbusters" group in court five times. "Mr. Negrete understands the intricacies of chiropractic profession and is the first to stand up to protect DCs who are under attack either from outsiders or from those within our own profession."
The World Chiropractic Alliance pledged its commitment of support to the Governor and the newly installed Board and their corrective actions. *Gov. Schwartenegger did VETO Senate Bill 801 in Oct. 2007 that went a long way in restoring normalcy to the chiropractic profession in CA.
POSTED: 11:23 p.m. EST, February 9, 2007
Most of the major insurance companies have adopted a take-it-or-leave-it approach with people filing minor-impact claims.
• State Farm, Allstate employ consultant's strategy, CNN research finds
• Theme of strategy is "deny, delay, defend," former employee says
• Companies convince juries that claims are fraudulent
• Insurers, institute deny treating claimants unfairly
By Drew Griffin and Kathleen Johnston
ATLANTA, Georgia (CNN) -- If you are injured in a minor car crash, chances are good that you will be in the fight of your life to get the insurance company to pay all the medical costs you incur -- even if the accident was no fault of your own.
That's what CNN discovered in an 18-month investigation into minor-impact soft-tissue injury crashes around the country. Those are accidents in which there is little damage to the vehicle and the injuries to people are not easy to see by the naked eye or conventional medical tools like X-rays.
Since the mid-1990s, most of the major insurance companies -- led by the two largest, Allstate and State Farm -- have adopted a tough take-it-or-leave-it strategy when dealing with such cases. The result has been billions in profits for insurance companies and little, if anything, for the public, according to University of Nevada insurance law professor Jeff Stempel.
"We can see that policyholders individually are getting hurt by being dragged through the court on fender-bender claims, and yet we don't see any collateral benefit in the form of reduced premiums even for the other policyholders," Stempel said. "So I think now we can say to continue this kind of program is in my view institutionalized bad faith." If you have never heard of the strategy, it's because insurance companies don't want you to know that they are paying out less and less for minor crashes even while their profits soar and your premiums continue to rise.
But after a review of more than 6,000 company documents and court records, interviews with a dozen people nationwide, including former company insiders, and conversations with accident victims, the picture is clear: If you challenge the offer by some insurance companies you will be left with no option but to go to court, where you will be dragged through the wringer.
In an affidavit in a New Mexico case where Allstate is being sued, one of the company's former attorneys said the strategy is to make fighting the company "so expensive and so time-consuming that lawyers would start refusing to help clients." Shannon Kmatz, a police officer and former Allstate claims agent, said company employees were encouraged to get rid of claims quickly and cheaply and even offered accident victims as little as $50, telling them to take it or leave it. Both Roxanne Martinez of Santa Fe, New Mexico, and Ann Taylor of West Lafayette, Indiana, saw the practice firsthand. Martinez suffered neck and back injuries when she was sideswiped by a driver insured by Allstate. After three years, the company finally offered her $15,000 -- a little more than half of what she needed for lost wages and medical bills.
She went to court, and four years after the accident a jury awarded her $167,000 plus interest. "It's kind of hard when you are thinking they are going to leave you broke. ... That was very stressful," she said. Taylor was not as fortunate when her case went to trial. The Indiana nurse was rear-ended by a State Farm employee driving a State Farm car. Damage to her car was minimal but she suffered herniated disc and muscle tears. Taylor racked up medical bills and lost wages amounting to about $15,000. The company offered her $2,000. "I was just very insulted," she said. She sued, but three years later a jury came back with a judgment for her of only $1,500. The jury didn't believe she could be hurt in an accident in which the vehicle had barely a dent.
Three jurors told CNN photos of the two cars involved in the accident -- enlarged and prominently displayed by the defense -- played a huge role in their decision. And one said they assumed Taylor had already been compensated by the insurance company and was just trying to get more money.
The cases, CNN found, illustrate a carefully developed strategy to make the victims look like they are trying to defraud the insurers. But documents CNN obtained indicate profit, not fraud, is the reason companies decided to play hardball in small accidents. For Allstate and State Farm, according to documents obtained by CNN, the strategy was developed in the mid-1990s with the assistance of consulting giant McKinsey & Co. Looking for a way to boost profits, McKinsey focused on soft-tissue injuries incurred in minor crashes. While the McKinsey documents -- numbered in the thousands -- are under seal in courts around the country, CNN saw several of them during a court hearing in Lexington, Kentucky. Playing off Allstate's signature slogan, one document recommends the insurer put boxing gloves on its "good hands" for those who insist on going to court. The strategy, according to former Allstate and State Farm employee Jim Mathis, relies on the three D's -- denying a claim, delaying settlement of the claim and defending against the claim in court.
"The profits are good, and as long as the community, the public allows this to occur, the insurance companies will get richer and people ... will not get a fair and reasonable settlement," Mathis said. Both Allstate and State Farm declined requests for interviews. In an e-mail, Allstate wrote it did not believe it would "have any real opportunity of being successful in getting you (CNN) to do a balanced report." State Farm wrote: "We take customer service seriously and seek to pay what we owe, promptly, courteously and efficiently, and we handle each claim on its own merits." The company also said, "Any attempt to generalize that State Farm adopted consultant recommendations as other insurers is just plain wrong." A company spokesman sent an additional e-mail, saying that the company did work with McKinsey to improve claims handling but State Farm stopped using the McKinsey program in 1999.
Robert Hartwig, president of the Insurance Information Institute, told CNN insurers do not have a strategy of blanket denial of claims. He also said strategies to limit expenditures on minor-impact crashes are needed to fight fraud. Hartwig specifically singled out lawyers who he claims make a living on car accident victims, saying those lawyers are upset because "the gravy train is over."
U.S. Closes Record-Breaking Financial Year for False Claims Recoveries
11/28 - National Legal News
The 2006 fiscal year, which ended on September 30, showed record-breaking recoveries by the United States government in the form of compensation for fraud. *Over $3B was recovered, largely via "whistle blowing" investigations and the rewards paid to those people. The biggest abuser was Tenent Health Care. This hospital network has been bilking the Federal Government for decades to the tune of billions of dollars. Their sad history of over $1B in fines and punishements is a testament to the "giveaway" mentality of Medicare and Medicaid.
False Claims Act Update & Alert
Taxpayers Against Fraud Education Fund | Washington, D.C. | WWW.TAF.ORG
Tenet's Long History of Fraud
1980s -- NME begins to diversify into specialty hospitals (psychiatry, substance abuse and rehabilitation) and aged care. By 1991 NME owns over 150 hospitals in the U.S., 115 of which were specialty hospitals.
1991 -- The Texas attorney generals charges NME with paying bounty hunters up to $2000 per psychiatric patient, resulting in a teenager being "kidnapped". The company settles the case for nearly the $10 million maximum.
1992 -- Investigations reveals that the activities going on in Texas are part of a nation-wide system in which NME changed diagnosis, and specialized on institutionalizing children for profit. Nineteen insurance companies commence actions against NME, and these cases are evenually settled for over $200 million. Also in 1992, shareholders begin proceedings against NME alleging the company with lying about the the bona fides of the corporation. These shareholder suits are eventually settled for $60 million.
1993 - NME's corporate offices and many of their hospitals are raided by the FBI.
1994 - The US Department of Justice commences criminal proceedings against NME, charging that the company paid kickbacks and bribes to doctors and others so they would refer patients to the company's psychiatric and substance abuse hospitals in 30 states, and that the company unnecessarily prolonged the hospital stay of patients. In June of 1994, as part of the largest health care fraud settlement in history up to that time, NME negotiated a $379 million settlement with the US Department of Justice and agrees to plead guilty on seven federal felonies. As part of the settlement NME was required to sell off its specialty hospitals and the company was restricted to operating more closely controlled general hospitals, which it was thought would be harder to cheat. In addition to the record settlement of $379 million, NME also paid $214 million to settle claims of fraud and paid fines to 28 state governments. It is also been reported that NME paid an additional $100 million to settle civil cases brought by plaintiffs, many of them children. Overall, the Company paid close to $1 billion in damages, civil penalties and criminal fines, and was required to sign a Corporate Integrity Agreement
1994 - Immediately after its guilty plea, NME merged with America Medical International (AMI) and renamed itself Tenet Healthcare, becoming the second largest hospital corporation in the U.S. The company says its new name "reflects its core business philosophy: the importance of shared values among partners - including employees, physicians, insurers and communities - in providing a full spectrum of health care. "
1994-2000: Tenet expands by buying, merging and partnering with not for profit community hospitals.
2001 -- Medicare outlier reimbursements account for 45% of Tenet's total earnings in FY 2001.
2002 - Medicare outlier reimbursements account for 41% of Tenet's total earnings in FY 2002.
June 2002: Tenet pays $55.8 million to settle a series of Medicare fraud charges, some initiated by whistleblowers. These include:
January 2003: Tenet agrees to pay $4.3 million to settle whistleblower-initiated allegations of pneumonia and septicemia upcoding at five hospitals.
Feb. 2003: Paid government $4.3 million to settle Medicare fraudulent claims allegations.
June 2003: The Internal Revenue Services demands $269 million from Tenent in additional taxes, including interest, for the years 1995-97.
August 2003: Paid government $54 million to settle allegations of unnecessary cardiac procedures at its hospital in Redding, California.
March 2004: Paid government $22.5 million to settle Medicare improper billing allegations and Tenet hospital entered into a new corporate integrity agreement.
Dec. 2004: Paid patients $395 million to settle Redding Hospital lawsuits.
Dec. 2004: Paid patients $31 million to settle Palm Beach Gardens (Florida) hospital lawsuits alleging patient suffering and deaths as a result of post surgical infections following heart surgeries.
2005: Tenet agrees to $215 million settlement to settle class action suit saying the company misrepresented its bonafides
Nov. 2005: Paid government $6.5 million to settle criminal investigation of Redding Medical Center allegations.
Jan. 2006: Announces $215 million settlement of shareholder lawsuits.
2005: Florida, Attorney General Charlie Crist files a civil racketeering suit against Tenet alleging the company inflated costs to rip off more than $1 Billion from Medicare. "Tenet systematically, consistently and in a prolonged way has been cheating the system," said Crist. Crist later settles all Florida claims with Tent for $7 million.
February 2006: Alvarado Hospital in San Diego is charged with violating federal anti-kickback statutes. The San Diego Union Tribune reports that federal prosecutors "in at least four other cities" are probing similar allegations against Tenet.
May 8, 2006: The U.S. Dept. of Health and Human Services announces it intends to exclude Tenet-owned Alvarado Hospital Medical Center in San Diego from Medicare, Medicaid and all other federal health programs.
Taxpayers for Common Sense: Access this site for the late Senator William Proxmire's now legendary "Golden Fleece" awards. This phrase and later on, WEB site, was initiated by this tax saving Senator who became disgusted with govermental waste and fraud. While gone now, he is certainly not forgotten. You will find the monthly "Fleece" awards as funny as they are depressing.
Fighting Insurance Fraud
William P. Barrett, 09.22.03, 11:21 AM ET
Stung by fraud-related losses estimated in the billions yearly, the insurance industry is working hard with law enforcement to implement corrective measures. But public opinion might just be standing in the way.
A survey by the industry-sponsored Insurance Research Council revealed that 25% of those polled thought that pumping up the value of a claim submitted to an insurer was OK. A full third said it was all right to do this to make up for the deductible, which is supposed to be an out-of-pocket cost paid by the insured. But at the same time, the report said only a quarter of insurers investigate cheating on insurance applications.
New efforts to combat insurance fraud include increased use of technology; stronger criminal and civil sanctions; and agreements allowing insurers to pool data as they look for insured who file huge numbers of claims against different companies. Other measures include psychological profiling and, in England, even lie detectors.
The insurance departments of the 50 states have formed the State Insurance Fraud Directors National Conference, which meets regularly to, among other things, flag the latest new insurance swindle. All but ten states now have some kind of official insurance fraud office. New Jersey has a dedicated insurance fraud prosecutor armed with a $30 million budget and tough new laws.
Obviously, a reduction in insurance fraud would increase the profitability of such publicly held insurers as MetLife (nyse: MET - news - people ), Hartford Financial Service (nyse: HIG - news - people ), Allstate (nyse: ALL - news - people ), John Hancock Financial Services (nyse: JHF - news - people ) and Cigna (nyse: CI - news - people ). Insurance industry experts claim fraud accounts for 10% of claims--something like $100 billion. But consumer advocates say the true number is unknown and quite possibly less. Insurers say they spend $650 million annually just in fraud detection, not counting losses.
Moreover, the insurance industry has been vowing a fraud crackdown for more than a decade, with nil results. This is not surprising. Fighting any kind of fraud on a large scale is difficult. It is labor-intensive and very expensive. Critics say many insurers--admittedly fearful of bad-faith-failure-to-pay-a-claim lawsuits--simply raise their rates to cover the fraud losses. Clearly, for many consumers, the bottom line is that there is not much of a penalty for small-time fraud.
But the anti-fraud efforts continue anew, in ways big and small. Florida just made it a second-degree felony to stage a car accident for the purpose of filing bogus lawsuits or making fake claims under the state's no-fault auto insurance law. Maximum sentence: 15 years. The Insurance Fraud Bureau of Massachusetts, an industry group, said this month it will pay a $5,000 reward for information leading to the conviction of persons involved in auto insurance scams--but only in Lawrence, where such claims are said to be filed at 3½ times the state average.
LexisNexis, the database company, is now marketing something called the Rate Evasion Evaluation service. It would verify that the information on insurance applications-- addresses, phone numbers, vehicle registrations--matches other databases and generates a risk score.
Insurance fraud seems to run in patterns. In the old days, favorite targets were health care and workers' compensation. Now auto fraud seems to be the rage.
Nor is insurance fraud limited to the U.S. In England, Carol Sergeant, head of the regulatory Financial Services Authority, told a recent symposium on economic crime at Cambridge University that the industry itself was to blame. "Many firms are still too reactive--they have not analyzed their vulnerabilities and put in place proactive prevention and detection strategies," she told the audience.
In the U.S., accounts of recent insurance fraud cases--prosecutions do seem to be on the rise--make for colorful, if sober, reading. Perhaps the most notorious case is that of Martin Frankel, the Connecticut financier who stole more than $200 million from small insurance companies he bought in Arkansas, Mississippi, Missouri, Oklahoma and Tennessee.
Just this month, David W. Dabney Sr. of Crestwood, Ky., drew a four-year prison sentence for being part of a ring that killed a man who had told police about a fraud scheme to burn nine houses for insurance. In Akron, Ohio, Terrance Jones was sentenced to three years for organizing a ring that staged fake car crashes and collected insurance proceeds.
In Nevada a jury convicted former North Las Vegas Councilman John Rhodes for submitting a fraudulent insurance claim worth $10,200. Rhodes said items had been stolen from his home. He faces five years in prison.
More information next time!
Dr. Haberströh is available for personal consultations on case files. He may be reached at 617.666.1767. For a more in depth file review and rebuttal, he is available for that too at a very reasonable fee. He is also very experienced in courtroom presentations. Call for details.
Please see our Publications page for Properly Documenting a File and Forensic Examination of IME Doctors, The Forensic Examiner (Fall, 2005, Vol. 14, #4, pgs. 26-39).
Our second major publication on IEs has been in print since 2006. With Kevin Mulhern, DC, we have our work published with THE FORENSIC EXAMINER: "Qualifications and Paradigms for the Independent Examiner." Check out our "Publications" page and download your own original copy of this groundbreaking article. *This article was also submitted to the Massachusetts Board of Chiropractic Registration in June, 2006 as a possible template for the ongoing revamping of the currently non-existent regulatory situation here in MA regarding IME doctors.
Number Three is Here! Our THIRD major paper on IEs has arrived. It is called: "Stories From the Front: IME Excesses and How to Counter Them." Cited at Haberstroh J, Mulhern, K, The Forensic Examiner, Vol. 17, #1. Spring 2008. The paper is out now in the Spring Issue of The Forensic Examiner. It has been posted on our Publications page. Thank you for your patience. We're very excited about this.