Written by attorney John Michael Phillips



by John M. Phillips

It happens more than you ever know. Rogue medical professionals have been committing silent malpractice on patients for years and the patients never know a thing. I first learned about it about 8 years ago, working with insurance companies. Certain physicians, medical clinics, chiropractors and other medical / pseudo-medical professionals have been injuring us all- not physically, but financially. Estimates say, it increases rates as much as $50-$100 per person because of fraud.

There are several methods of abuse that are commonplace. Medical professionals are billing for procedures not performed, billing more than they should for visits and/or otherwise inappropriately billing insurance carriers for hundreds of millions of dollars. Under Florida’s Personal Injury Protection (PIP) law, automobile accident victims have up to $10,000 in benefits for medical treatment and, in the wrong hands, their injuries are further being involved with (and insulted by) fraudulent billing practices. We watch out for that and have advised insurance carriers, medical professionals and victims of their rights.

Every medical procedure -whether knee surgery, heart transplant or chiropractic manipulation- is ultimately boiled down by your doctor into a series of codes in order to submit bills to insurance carriers to get reimbursed. The importance of coding for services and procedures has evolvedin recent years. Up until several years ago, codingwas seen as a method to classify the services and proceduresthat physicians provided to their patients. Now, codinghas evolved into a system used principally to determine -andlimit- the reimbursement physicians receive for their services.

Coding is the process by which a service or procedure is labeledwith a code to categorizethe service or procedure. The codes are called “Current Procedural Terminology," or CPT codes. Coding is difficult, as it is. Sometimes it is hard to put a code on a condition and a personal service. Additionally, there is often discretion in whether to code something one way or the other. Mistakes happen, but the insurance industry has realized that abuse and fraud is rampant. More than $850 million in phony insurance claims have been filed in Florida, alone. As an attorney with Morgan & Morgan, I attended countless Examinations of MY client, because the insurance company wanted to conduct an investigation of what services THEIR doctors performed. Questions like- “Did the doctor do (this kind of procedure)?" “Have you ever seen (this device) before?" “How long was the visit?" Certain physicians are, frankly, known cheats and need to be prosecuted and avoided at all costs. Code Blue.

Think of John Grisham’s novel, The Firm. We excerpt it below. Essentially, the firm got brought to its knees because of a small amount of excessive billing that grew large because it was done over and over and over again. The same concept applies with medical billing. When a doctor bills for a procedure he or she didn’t do, or upcharges for one he or she did do, and does it with every patient, that number grows COLOSSAL over time. Further, doctors who commit fraud tend not to be honest with patients and overly concerned with their own interests and financial gain.

Medical professionals may be subject to accusations of civil and criminal fraud for codingperformed by office personnel if coding is incorrect and thephysician knew or should have known that the coding practiceswere incorrect. However, most pitfalls in coding can be avoidedwith a thorough knowledge of codes and coding policy. Most practices implement one person to do the billing or computer software that standardizes this practice. We also advise practices regularly. It isthe ethical responsibility of physicians to code for their servicesaccurately, and accurate coding has the additional benefit ofminimizing exposure to allegations of fraud.

A Case Study- Eileen Dvorkin

Eileen Dvorkin was a 30-year Miami chiropractor, who was recently caught on hidden camera paying patients to say she gave them treatment. According to allegations, she would pay as much as $800 to patients who are willing to say they were in accidents that never really happened. Meanwhile, she would submit milling and recover Personal Injury Protection (PIP) benefits.

Insurance carriers are abusing the system, too. It has led to more systematic denials of benefits and so many hurdles that many practicing physicians have gotten out of the treatment of accident victims. Since the Amendment of Florida’s PIP Statute in 2008, one particular carrier seems to frequently deny payments for CPT Code 97124 (Massage, including effleurage, petrissage and/or tapotement aka stroking, compression and percussion) when it is performed on the same date as CPT Code 97140 (Manual Therapy Techniques aka mobilization/manipulation, manual lymphatic drainage, manual traction). Every situation should be looked at separately. Everyone, simply, should ethically (and legally) do what they are supposed to do.

Point is- go to a physician you trust and examine his paperwork and any explanations of the treatment you received to make sure it is accurate. We offer free consultations and are happy to help however we can.

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John M. Phillips

** [email protected]**

Licensed in Florida, Georgia and Alabama

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