California Insurance

REAL real doctors performed procedures on real patients. The insurance claims were real, the surgery centers that the dossier. And the money that insurers paid - a total of about 500 million USA, federal investigators believe - Verily, verily was authentic.

Hundreds of people, including many new immigrants is not with America’s health care system to voluntarily submit to medical tests and operations. She traveled to centers of operation in Southern California for what would be in another context, routine procedures like endoscopies, colonoscopies and lubricates PAP. Some have traveled in hospitals “dimethanonaphthalerne by far as Tennessee. Some of them, investigators said, given or received free plastic surgery and others have received cash.

Such a payment was and still is illegal.

Insurers, meanwhile, were billed to tens of thousands of dollars for each of these procedures, far more than it would have paid if the patients were in the network of providers.

Over the past two years, federal, provincial and insurance industry investigators have unraveled what they say, is one serious cases of manipulation by doctors of confidence in it. But this type of fraud - which relies on a network of doctors, surgery center owners and staff, patients and staff intermediary known as “cappers” - is difficult to detect and stop. The CA is just the beginning.

Last summer, federal prosecutors and received a number of owners of the operations centre of fraud. In the spring of this year, several Blue Cross Blue Shield and complaints filed against civil society in several centers, their owners and more than a dozen doctors.

Health Insurance Fraud is a big company. The National Health Care Anti-Fraud Association has estimated that $ 1.7 trillion on health care to the USA in 2003, from 3 to 5 per cent of fraud was lost, violent, that insurers pay claims that companies pay premiums and patients, asked to pay assume, more and more of the burden.

Given that the lowest value, you will reach $ 51 billion, “said Michael J. Costello, the Association of Heads of the investigation. It works to more than $ 100 million per day, he said, and “If it’s not receive attention, nothing.”

Discovery of a well-constructed fraud can be very difficult because nobody has an incentive to blow the pipe - and not doctors, is not the owner of the clinic, not patients, bribes and some critics say, not even insurer, you can simply raise premiums to cover its costs.

If investigators “Given the CA is true,” it is not only doctors do, what is wrong, “said Dr. Susan Dorr Goold, director of the bioethics program at the University of Michigan.” There are many people who bad thing.

A great effort to identify surgery centers of the fraudulent billing had its genesis probably during a routine meeting by the insurer in January 2003, in Tampa, Florida leaders have met three times a year, to compare notes on suspicious activity, but that meeting was somewhat unusual because, according to the insurer insurer had observed the same thing: patients were driving times and flying hundreds, even thousands of kilo-meters to submit suspicious routine.

“We all kind of look immediately and said:” What’s going on here? “Remember, Byron Hollis, national anti-fraud director of Blue Cross Blue Shield Association.” It was obvious that we have a problem Coverage territory. “