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

January 18, 2010

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!


Texas D.O. – Daniel Andrew Maynard – Pays $253,000 to Resolve Allegations of False Health Care Claims!

May 2, 2008

As an ethics speaker, I am not sure why. Perhaps the US Attorney’s office didn’t have enough to convict. Whatever the reason, there was resolution in a case in the Northern District of Texas from a Texas D.O. – Daniel Andrew Maynard and the US Attorney’s office.

By entering into a settlement, Maynard admits no wrong-doing and denies all liability. However, the very fact that Maynard is paying over a quarter of a million dollars says something.

According to the US Attorney’s office, in February 2005, the Office of Inspector General for the Department of Health and Human Services (OIG), the Texas Health and Human Services Commission, Office of Inspector General (HHSC), and the Federal Bureau of Investigation referred allegations to the government that Maynard had inflated billings for thousands of physician evaluation and management services submitted to the Medicare and Texas Medicaid programs. The U.S. and Texas allege that on at least 32 separate days, Maynard billed both programs for patient encounters – that if provided as claimed – meant he spent more than 24 hours each day seeing and treating patients. Maynard claimed to have seen more than 100 patients on six of those occasions. The U.S. and Texas contend that contrary to Maynard’s claims, he could not have possibly furnished anything more than the most basic of physician services during those 32 days.

Hum…guess Maynard was a work-a-holic? While, again, according to the settlement there was no admission of wrongdoing, the fact remains that a substantial sum has been paid to correct what appears to be incorrect behavior.

Further, as part of the civil settlement, Maynard agreed to be permanently excluded from participation in Medicare, Texas Medicaid, and all other federal health care programs. Maynard previously pleaded, in October 2007, no contest to several Dallas County criminal counts charging him with delivery of a prescription or prescription form without a valid medical purpose.

According to a 2003 news release, Maynard has had issues with his medical practice. The news release stated: “Dr. Maynard’s office was raided by local, state and federal law enforcement officials based on information regarding non-therapeutic prescribing, medically unnecessary prescribing and possible patient harm, including deaths, as a result of his prescribing activity. The panel determined that Dr. Maynard had violated several provisions of the Medical Practice Act by failing to keep adequate medical records related to treatment of Intractable Pain Patients; failure to practice medicine in an acceptable professional manner consistent with public health and welfare; committing unprofessional or dishonorable conduct that is likely to deceive or defraud the public; and by prescribing dangerous drugs and controlled substances to persons who are known or should have been known to be a drug abuser.”

Every choice has a consequence. So far, Maynard should be pleased that the consequence was civil – not criminal. He may, by agreeing to a civil settlement, be able to keep his medical license. However, since he cannot participate in either federal or Texas state health care programs, his client base will likely be limited.

Feel free to share your comments!

Business Ethics Speaker – Chuck Gallagher – signing off…


Texas Doctor Sentenced to 97 Months In Federal Prison for Bribery! Samuel M. Theagene What Were You Thinking?

February 2, 2008

You spend year after year in grueling medical school to achieve you life long dream. Then one day you wake up to find that it was only a “dream.” That’s the day you wake up and find yourself in federal prison. And each day there after you find that one day is the same as the next – and so it goes for eight long years.

jail-cartoon.jpg

That’s exactly what Samuel M. Theagene, M.D. will soon be facing. 8+ years in prison – and for what?

Between October 3, 2006, and February 21, 2007, Theagene, president of the Pain and Neuromuscular Clinic of Texas, P.A., paid a Revenue Officer of the Internal Revenue Service $16,500 in United States currency to absolve his tax liabilities.

Now what was he thinking? Surely a medical doctor has enough common sense to know that bribery of a federal official wouldn’t work? Surely, he would have calculated the risk/reward ratio and figured that he really couldn’t win this battle?

Well, the investigation began in October of 2006, when the Defendant sent $500 cash to the Internal Revenue Officer working on the collections case. Attached to the five one hundred dollar bills was a note which read “A Token.”

Now that was smart (yea right)! However, he might have played that off as a payment toward his bill. Not so fast. His next moves gave away his intent (criminal intent I might add).

Thereafter, the Defendant offered to pay the Revenue Officer 10% of the approximate $160,000 business tax liability to eliminate the debt. Between October of 2006 and February 2007, the Defendant paid the Revenue Officer cash installments of $1500, $5000, $5000 and $4500. At one of the meetings, the Defendant asked for forgiveness of his personal tax liability as well. All of the payments were made by the Defendant to the Revenue Officer in area restaurants.

Not only is Doctor Theagene going to prison, but I’d bet that the IRS is not letting off the hook without paying the liability in question.

Every choice has a consequence. Likewise, you do reap what you sow. Sadly for Dr. Theagene his choices earned him time in the slammer. I do promise this – when he gets out he will wish he’d just paid what he owed.

Business ethics and White Collar Crime speaker – Chuck Gallagher – off for now…