US Doctors Involved in Health Insurance Scam

Now here's a great reason not to trust everything that comes out of your doctor's mouth: in an article from the LA Times, 3 doctors are being held for doing "unneeded" procedures at a Buena Park clinic. What they were doing is recruiting patients for these unneeded procedures, in exchange for either cash or low-cost plastic surgery. 

Would you get a plastic surgery operation from a doctor that was willing to defraud an insurer for a living? I sure wouldn't!

These weren't no-name doctors either. The three being held are Michael C. Chan, a Cerritos obstetrician, William W. Hampton, a Seal Beach surgeon, and Mario Z. Rosenberg, a Beverly Hills gastroenterologist on staff at Cedars-Sinai Medical Center. However, perhaps the regular salary of a doctor just wasn't quite enough. These three are part of a ring of 17 people who have bilked insurers for a total of $30 million. After you pay for the "real" medical costs of having each patient recover from the surgery, and pay-off the recruiters who found the dupes, you still walk away with a tidy profit. 

Of course, the doctors deny all the charges. We'll have to wait and see if the courts find them guilty or not. I'm going to guess that some kind of plea-bargain will be the probable result. However, all is not well for these three physicians: there are already 3 recruiters and 1 administrator who have either been convicted or have plead guilty and are awaiting sentencing.

All this brings me back to the topic of health insurance. If your insurance restricts your access to doctors, is this a good thing? It depends on how closely the insurer is actually monitoring those physicians who are within its network. However, it can also be a bad thing, because it may mean that you can't get your procedure done by the right doctor -- and get it paid for.

Fraud also drives the cost of health insurance up. It's not just an individual crime; it's a crime that will affect all the people who have policies with the insurers that were defrauded. Fraud drives up premiums; it's that simple.

As a result, you really have to be careful when you pick a health insurer. You could be paying too much if the insurer has had a bad fraud history. You could also find that you don't get access to the right doctors or services. You really have to do your homework. Check out my tips on how to pick health insurance well.

To my mind, it makes the Canadian system, where there is a single payor (the governmentally-run insurance "company") who is also able to sanction a doctor, look a lot safer and more secure. While there's still fraud, if you have one payor, it can be caught much more quickly because the information on payments is going through one agency. While there is still negligence, when there is one payor, it too can be found and sanctioned much more quickly.

Monique L. Attinger 

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