When Prostate Cancer Returns – Ouch Mayo Clinic Fumbles the ball… Part 9

Some posts are simple and don’t require many words.

Mayo Clinic pre-certification department – 100% satisfaction rating.  Talking about a group that has gone above and beyond the call of duty…these folks certain have.  Hats off to you.

Mayo Clinic Urology dept… well it started at 100% and I can honestly say they are good – real good – but when it comes to patient first or process and time – patient loses if they pay with insurance.

Let me explain.  National Imaging Association denies the C-11 Pet Scan which would be the most likely test to determine the source of my recurrent prostate cancer.  What they require is a Peer-to-Peer consultation with the folks at the Mayo Clinic.

Why?  Likely because this particular Pet scan is so highly specialized that the NIA folks need to be “convinced” (my word) that its useful in my case.  To be fair, Dr. Kwon, through the Mayo pre-certification dept sent extensive material to help them understand.  Do I think the folks at NIA read it – na…not a chance.

But the problem is – Dr. Kwon and the Mayo Urology folks don’t (won’t) do peer-to-peer consultations with insurance companies.  I was told if they did that is all they would do and therefore get no scans done.

Wait a minute…time out.  You’re telling me that you (the Mayo Clinic) can’t hire someone with clinical urology experience to handle the interaction with insurance companies so that patients (like me) don’t get caught in the health insurance circle of death?

Sorry, but it is unacceptable that no one with enough specialized knowledge from Mayo Urology can take the time needed to do the peer-to-peer knowing that this test is “the” test needed to help me get appropriate direction needed for an effective treatment.

One call, but the Mayo Clinic won’t make that… at least that’s what I have been told for two days.  So much for the patient coming first.  Remember I (your patient) didn’t create this screwed up system of health care or payment system.  I just need cooperation so I can move forward to eliminate this disease once and for all.

You sure you won’t make the peer-to-peer call?  Please!

When Prostate Cancer Returns – The Great Health Insurance Run-around! – Part 8

I am becoming more firmly convinced that the health care system is so screwed up that recovery is challenging at best.  Wonder if we should call in palliative care for our health care system?

Many of you have been following my journey dealing with recurring Prostate Cancer.  Treatable?  Yes!  Easy?  No!!!

THE GREAT INSURANCE RUN-AROUND!

Yesterday was a red-letter day when it comes to getting the run-around from all sources.  Even the great Mayo Clinic contributed (but we’ll get to that later).  Since this is in two parts – the first part was posted yesterday and can be seen here:  https://chuckgallagher.wordpress.com/2013/11/26/health-insurance-companies-and-the-ethics-of-health-care-you-aint-gonna-believe-this/

In my case since I was denied the test that I need to identify the source of my recurrent prostate cancer, I elected to call Blue Cross – Blue Shield of SC.  Ooops…calling – well that’s not possible.  Rather you have to communicate through their BC/BS website (something I can do, but not sure it’s easy for all customers/patients).  The connection with BC/BS was to appeal their denial.

BC/BS says – Sorry, but National Imaging Association is who issued the pre-approval denial and they would have to be the ones to reconsider.  Fair enough…

So I call National Imaging Association and was told that I was denied because the Mayo Clinic in its submission for approval indicated “Prostate Cancer” but did not provide a “tissue diagnosis”?  Bureaucratic bulls**t.  What tissue is there to diagnose?  My PSA is rising and that has only one practical source – recurrent prostate cancer.

CHINK IN THE MAYO CLINIC ARMOUR

Following the logical process…I follow up with the Mayo Clinic pre-certification folks and am told that they have done all they can do and that a peer-to-peer might be in order.  Seems reasonable to me.  So I am told to talk to Dr. Kwon’s admin to seek his help.

Moments later I talk to Dr. Kwon’s admin and, well I must have called either on a bad day or too late in the day.

“Why are you calling me?”

“The folks at the Mayo pre-authorization or certification dept told me to call as a peer-to-peer might be in order,” was my response.  They just told me this minutes ago.

“They shouldn’t be doing this.  Dr. Kwon is not going to do a peer-to-peer with an insurance company.  Do you mind if I put you on hold while I resolve this with the pre-authorization dept.  They should have never had you call me.”

On hold…and I’m thinking “well that didn’t go well” – as the patient what message was sent that my doctor who is the champion of this particular procedure would not do a peer-to-peer.  I really do get it…that is time and time is money, but reality is if that is what is required surely there is a solution other than complaining about receiving a re-referral from another department within the Mayo organization.

THE GAME

I’m becoming more and more confident that the insurance company game is played this way:  DENY! – wait and see if the patient or doctor’s office gives up = INSURANCE COMPANY WINS!

Well, I don’t give up that easily either with the insurance company or the Mayo Clinic.

Looks like its back to the phones for me!

YOUR COMMENTS ARE WELCOME!

Health Insurance Companies and the Ethics of Health Care…You Ain’t Gonna Believe This!

Some may know – especially those who have been following my most recent blogs related to a return of Prostate Cancer that I’ve been dealing with – but today was a Red Letter day when it comes to Health Insurance, Health Insurance Companies and how they ethically (oops unethically) deal with their customers.  I am not sure how we got here, but where we are when it comes to our health and how that is paid for is so broken it’s quite unbelievable.

WHAT’S THE SCOOP?

Today was a follow up visit with my local doctor.  Nothing special and almost a waste of time, but the appointment was scheduled and kept.  Routine visit – weight, blood pressure, temperature, and nothing unusual.  Today I was to receive the results of my bone scan and CT scan, but since I got a CD with the data ready to send to the Mayo Clinic (which of course I read – not that I’m a doctor, but I can read, and a report that says nothing was found was exactly what I was expecting), which I sent, I knew the outcome before the visit.

Doctor enters the room with a pleasant smile asking me how I am.  Now that was a loaded question since I am full of frustration over the way Health Insurance companies deal with their customers (namely me).  Of course since I am the one that wants treatment, I personalize their actions.  Yes, I know better, but to me it is personal since it is my health.  So…I proceed to vent to the doctor.

“Doc, I don’t know how you deal with these insurance companies day in and day out!  They are a pain in the ass.”

“You don’t know the half of it,” he responded, “and it’s only getting worse!”

For a few minutes he openly allowed me to vent, then looked at me, removing his glasses and said, “Let me vent a bit.”

AMAZING STORY!

Of course with no identifying information shared, my doctor shared with me the most amazing story I’ve heard (and I suspect that this is nothing in comparison to many many more stories like this out there).

“So I have a patient with advanced lung cancer.  He’s been a smoker most of his life, so as you can imagine his lungs are pretty damaged.  Likewise, he has cancerous lymph nodes in his chest.  So I suggested a form of radiation treatment that is more localized to his tumor so that I can spare what little lung he has left.  If I use traditional radiation the tissue damage will create substantial problems for this man who needs to salvage as much of his lung as possible.

I submitted my request to his health insurance company.  Their reply:  DENIED.  They wanted me to use the conventional treatment!

I told the person on the phone, because by now I was personally involved, that if it were their lung or even their father in a similar situation, they would want the better treatment.  The treatment that would salvage what lung he has left.

They then suggested that I resubmit the request showing the two treatments: (1) more effective treatment and (2) conventional tissue destroying treatment.  We did that.

Got the response today:  DENIED!

I was incensed and called again for a peer to peer discussion.  Not more than 30 minutes ago I was told that the conventional treatment was all that was needed, even though I know that the damage from that will substantially diminish his quality of life and could create more medical costs down the road.

Chuck, they just don’t care!”

HOW DID WE GET HERE?

How did we get to the point that a person checking off a checklist is the determining factor into the kind of health care we receive in the United States of American?  Are we really OK with care provided at the lowest common denominator?  We we can receive quality treatment but the insurance company will only pay for adequate treatment, is that OK?

SHARE YOUR STORY

You don’t have to name names, but feel free to share your story.  Maybe if enough of us get our stories told…SOMEONE WILL LISTEN.

FEEL FREE TO SHARE YOUR STORY OR YOUR COMMENTS.

Birdie Leroy Revis pleads Guilty to Multi-Million Dollar Health Care Fraud Scheme… Choices and Consequences…

HOUSTON – An accused recruiter in a multi-million dollar health care fraud scheme scheduled for trial on Monday, has instead pleaded guilty to conspiracy to violate the Anti-Kickback Statute, United States Attorney José Angel Moreno announced today. Birdie Leroy Revis, 60, of Houston, pleaded guilty before United States District Judge David Hittner this morning to conspiracy to violate the Anti-Kickback Statute. Trial had been scheduled to begin with jury selection on Monday, Aug. 8, 2011.

Revis was a recruiter for Sefan Medical Supply (Sefan), a durable medical equipment provider, located in Houston. Based upon the joint investigative efforts of the agencies comprising the Medicare Fraud Strike Force into a $2.8 million scheme to defraud Medicare by Sefan, evidence was obtained proving that Revis’ role in the scheme was to provide Medicare beneficiary information to Sefan. Sefan, in turn, then billed Medicare for medically unnecessary durable medical equipment and supplies which were either not provided to Medicare beneficiaries or a lesser product from what was billed to Medicare was provided. The information was provided on a prescription form for arthritis kits. All the kits included a knee adjustment with air chamber, rigid frame back brace, elbow with joint, ankle gauntlet, flex glove with elastic finger, heat lamp with stand and a wrist brace. Sefan would order these items for both the left and right side. If the beneficiaries received any items, they did not receive the rigid brace items billed to Medicare, instead they would receive neoprene sleeves, which was not covered by Medicare.

Revis provided to Sefan information for more than 686 beneficiaries for which Sefan paid Revis approximately $400 per beneficiary for a total of more than $353,000. With the information provided by Revis, Sefan billed Medicare for more than $2.8 million worth of claims for arthritis kits and was paid more than $1.7 million for those fraudulent claims.

Revis remains on bond pending sentencing, which is set on Nov. 2, 2011. Revis faces a maximum of up to five years in prison to be followed by up to a three-year-term of supervised release and a fine of up to $250,000 for the kickback conspiracy conviction.

The owner of Sefan and the physician whose signature was on the prescriptions have also been convicted following their respective pleas of guilty to conspiracy to commit health care fraud. Kate Ose Olear, the owner of Sefan, was sentenced to 57 months in prison on Feb. 10, 2011, by United States District Judge David Hittner. John Edward Perry III, the physician, pleaded guilty in June 2010. He remains on bond pending his sentencing on Oct. 21, 2011, before United States District Judge Gray H. Miller.

The investigation leading to the charges in this case was conducted by the Medicare Fraud Strike Force comprised of agents with the Department of Health and Human Services, Drug Enforcement Administration Diversion Division, Texas Attorney General Medicaid Fraud Control Unit, United States Railroad Retirement Board and the FBI. Assistant United States Jennifer Lowery and Special Assistant United States Attorney Justin Blan are prosecuting the case.

Medicare Fraud earns Dr. Rene De Los Rios 235 months in Federal Prison. Comments by Ethics and Fraud Prevention speaker Chuck Gallagher

The following is a news release from the Department of Justice.  Please note – EVERY CHOICE HAS A CONSEQUENCE!  As an ethics and fraud prevention speaker to numerous governmental agencies including the FBI – it is clear that regardless of how clearly wrong choices like this may be, the fact remains that unless there are safeguards put in place to remove one of the three components that allow an ethics person to make unethical and illegal choices, we will continue to have frauds like this and the consequences that follow.

If you know of Dr. Rene De Los Rios and have insight into the doctors thinking…feel free to share your comments below!

WASHINGTON – Miami doctor Rene De Los Rios, 72, was sentenced today to 235 months in prison for his participation in a $23 million HIV injection and infusion Medicare fraud scheme , announced the Departments of Justice and Health and Human Services (HHS).

U.S. District Court Judge Joan A. Lenard of the Southern District of Florida also sentenced De Los Rios to three years of supervised release following his prison term and ordered him to pay a minimum of $11.7 million in restitution, jointly with his co-defendants.  The final amount of restitution will be determined at a later hearing.   On April 14, 2011, De Los Rios was convicted by a jury of one count of conspiracy to commit health care fraud and four counts of submission of false claims.  De Los Rios was remanded to the custody of the U.S. Marshals Service after his conviction and has been detained since that time.

According to evidence presented at trial and sentencing, De Los Rios worked at multiple fraudulent medical clinics and signed medical documents authorizing tests and treatments that were medically unnecessary or never provided.   The court found De Los Rios responsible for a total of $46 million in fraudulent billings to Medicare.

According to evidence presented at trial, De Los Rios was hired by the owner of Metro Med of Hialeah Corporation, an HIV infusion clinic that purportedly provided injection and infusion therapies to HIV-positive Medicare beneficiaries.   Evidence presented at trial established that De Los Rios ordered unnecessary tests, signed medical analysis and diagnosis forms, and authorized treatments to make it appear that legitimate medical services, including injection and infusion therapies, were being provided to Medicare beneficiaries at Metro Med.  However, the injection and infusion therapies were medically unnecessary and never provided.   De Los Rios also signed medical charts, often without seeing the patient, indicating that certain treatments were medically necessary, when, in fact, he knew they were not.

Evidence at trial established that De Los Rios diagnosed almost all of the patients at Metro Med with the same rare blood disorders, which the patients did not have, in order to ensure maximum reimbursement from Medicare.  The evidence at trial also showed that De Los Rios prescribed expensive medications, including Winrho, Procrit and Neupogen, to patients for the sole purpose of receiving reimbursement from the Medicare program.  From approximately April 2003 through October 2005, Metro Med submitted approximately $23 million in claims to the Medicare program for injection and infusion treatments that were not medically necessary and were never provided.  The Medicare program paid approximately $11.7 million in claims.

The owner and operator of Metro Med, Damaris Oliva, and three other individuals have each pleaded guilty for their roles in the Metro Med fraud scheme.   Oliva was sentenced in December 2010 to 82 months in prison.   Co-defendants Estrella Rodriguez, Jose Diaz and Lisandra Aguilera were sentenced to 57 months in prison, 54 months in prison and 70 months in prison, respectively.

Evidence at trial and sentencing also established that De Los Rios engaged in almost identical conduct at additional sham HIV injection and infusion therapy clinics in South Florida during the same time period.  At J&F Community Medical Center Inc.  and Rochris Medical Center Inc., De Los Rios prescribed the same medications that he prescribed at Metro Med to patients who he knew did not need them.

In a two-and-half-year period, De Los Rios made more than $587,000 in profits from the fraud schemes.

At sentencing, the court also found that De Los Rios obstructed justice by testifying falsely at his trial; that as a doctor, De Los Rios occupied a position of trust, which he violated; and that by prescribing medically unnecessary injections and infusions for HIV-positive patients, De Los Rios caused a reckless risk of serious bodily injury to those patients.

The court declared a mistrial in De Los Rios’ first trial in March 2011.

Today’s sentence was announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; John V. Gillies, Special Agent-in-Charge of the FBI’s Miami Field Office; and Special Agent-in-Charge Christopher Dennis of the HHS Office of Inspector General (HHS-OIG), Office of Investigations Miami office.

The case was prosecuted by Trial Attorney Joseph S. Beemsterboer of the Criminal Division’s Fraud Section and Robert J. Luck, Assistant U.S. Attorney for the Southern District of Florida.   The case was investigated by the FBI and HHS-OIG, and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.

Since its inception in March 2007, the Medicare Fraud Strike Force operations in nine locations have charged more than 1,000 defendants and organizations that collectively have billed the Medicare program for more than $2.3 billion.  In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to www.stopmedicarefraud.gov .

YOUR COMMENTS ARE WELCOME!

Does Scott Brown’s Win mean Health Care Reform should be Scrapped?

With a decisive win in MA, Scott Brown has taken a Senate seat that was held by Ted Kennedy for decades.  Kennedy, of course, is known as the primary supporter and author of the Health Care Reform bill that is currently before Congress.

Now, President Barack Obama and the Democrats, which held the the 60-vote Senate majority that they’ve relied on to push a historic health care overhaul to the verge of enactment, find that they may see Health Care Reform derailed before enactment.

According to MSNBC – Democrats splintered on how to salvage the president’s top domestic initiative even before the results were official. Republicans said don’t bother: The election of state senator Scott Brown sent a message that the health care bill should be scrapped.

Democrats don’t appear to have enough time to resolve differences between the House and Senate bills — and get cost and coverage estimates back from the Congressional Budget Office — before Brown is sworn in. That leaves House Democrats with the unpalatable option of passing a Senate bill that many of them profoundly disagree with.

“There is only one guarantee — that if we don’t pass something the notion of trying to put Humpty Dumpty together again is a real long shot,” said Rep. Patrick Kennedy, D-R.I., son of the late senator. “If you understand the legislative process, it’s a lot easier to pass something and fix it later.”

So as the days unfold several questions arise:

1. Should Health Care Reform be scrapped?
2. Should Health Care Reform be revisited and move forward more slowly, but with the intention of passing something?
3. Is Brown’s election a broader measure of Obama’s political support?

YOUR COMMENTS ARE WELCOME!

Scott Brown Wins Massachusetts Senate Race – But Ethical Deicsion now – Does US House Push through Legislation before Brown is seated?

With 89% of the results counted, Republican Scott Brown won a major upset victory in Tuesday’s special election for the U.S. Senate seat formerly held by liberal Democrat Ted Kennedy.   The irony is that Kennedy was known for his strong support of Health Care Reform and Brown’s campaign was focused on being the 1 vote that could derail the proposal before the conference committee of the House and Senate.

US HOUSE CONSIDERS SLIPPERY TACTICS:

It is now reported that the House may be considering passing an unamended Senate health care measure.  If that were to take place then President Obama could sign the bill into law without considering to Brown’s vote.  A CNN article is here.

House Speaker Nancy Pelosi added, “Whatever happens in Massachusetts, we will have quality, affordable health care for all Americans, and it will be soon.”

Several Democratic congressional sources tell CNN that having the House approve the Senate bill is probably the best of a series of bad options to pass health care reform in the event of a Brown victory.

ETHICS ISSUE:

As an ethics speaker and author…I must admit that I am amazed.  If Brown’s election is a representation of something larger than just a local Senate election (and with all the coverage – it is bigger), then how could our elected officials ignore the legislative process and deny Brown his opportunity to represent the people of MA.  It would appear that, should the House pass the Senate version, then it would be clear that “Change from politics as usual” that many people felt they were voting for was just a misguided belief.

What we see happen in the next few days will define our nation.  We are either a democracy that respects the will of the people or we have become so consumed with power, agenda and greed that we will have a much harder battle to restore respect and ethics to our government.

I hope that folks (regardless of your political persuasion), or better stated, government elected officials, will allow the legislative process to continue without making the unethical decision to force and agenda.

VOICE OF REASON:

Sen. Jim Webb of Virginia said in a statement Tuesday after Brown defeated Democrat Martha Coakley in the special election for the late Sen. Edward Kennedy’s seat.

“It is vital that we restore the respect of the American people in our system of government and in our leaders. To that end, I believe it would only be fair and prudent that we suspend further votes on health care legislation until Senator-elect Brown is seated.”

YOUR COMMENTS ARE WELCOME!

When did the Insurance Company become Your Doctor? Wonder if Insurance Companies have any Ethics?

You can tell it’s winter when you start to find yourself hanging around people who seem to have the upper respiratory crud.  Unfortunately, both my wife and I have been dealing with it.  You know – coughing and sneezing, etc.  Now, I’m sure you didn’t start to read this to find out our medical condition, but it sets the stage.

My wife, not one who likes to go to the doctor, broke down today and paid the Doc a visit.  Sure enough she had a form of bronchitis for which the Doctor prescribed an antibiotic.  So far so good.  She paid her co-pay and went on to the pharmacy.  Her prescription was filled and all seemed well.

Well…that is…until she checked out the instructions to the antibiotic.  Instructions stated “take one pill each day for five days.”

STOP!

One would assume that there were five pills since the she was to take one each day for five days.  But when she opened the bottle – there were four pills.  “Wal-Mart”, she thought, they shorted her a pill.  So she called them.  The result…no shortage.

Seems that the INSURANCE COMPANY says they will only pay for four pills.  WHAT?  YEP.  They will PAY FOR 4 PILLS.

Now, when my wife told me this, we both shared our disbelief.  A prescription that should be completed – (take 5 pills) – was shorted by 20%.   Maybe it’s a myth, but I was always told that to be effective a prescription should be taken through completion (i.e., all 5 pills).

MY QUESTION:  When did INSURANCE COMPANIES become the DOCTOR?

So, on the way home, I stop to get come cough syrup and ask the pharmacist what the deal with this is.  His response.  “You don’t have a clue how bad it is and it’s getting worse.”  INSURANCE COMPANIES are effectively practicing medicine and we’re letting it happen.

So, as a business ethics speaker and author, I wonder, do you feel that this right?  Are INSURANCE COMPANIES practicing medicine?  And, when did the Doctor lose control of the care of his/her patients?

I bet you have stories too…feel free to share…

YOUR COMMENTS ARE WELCOME!