CHIROPRACTIC UNDER ATTACK BY INSURANCE COMPANIES
There has been a major insurance company and Department of Insurance focus on charging chiropractors with crimes. Insurance companies do not like to dispute bills in the Worker’s Compensation court system or Superior Court for personal injury cases. They often lose. Large chiropractic bills have been sustained at trial and in arbitration. Often chiropractors point to the fact that they provide relief without opioids or surgery. At trial the cost of chiropractic care is balanced against the costs of surgery or the dangers of addiction. However, the insurance company computers track average billings per average injury and practices generating numbers out of the “norm” are targeted. SIU units made up of retired law enforcement agents will prepare SIU attorneys to take depositions and gather material as if the chiropractor is committing fraud. Your practice gets spun by these professional “spin doctors”. The case gets packaged and is sent to a favorable district attorney for prosecution. At some point, the chiropractic board is involved.
Daniel Horowitz is well known for his successful defense of chiropractors. His chiropractor defense team includes Michael Yates, D.C. / J.D.. Michael is a law school graduate who is currently licensed as a chiropractor.
TO DEFEND CHIROPRACTORS – WE FOLLOW THE MONEY
As a former Assistant District Attorney Tom Kensok supervised and charged hundreds of criminal cases, including health care fraud cases. He was careful not to charge a medical doctor with fraud unless he was certain of the doctor’s guilt. He knew that if he charged a doctor with fraud and later learned that the doctor was innocent, the harm to the physician’s career could still be irreparable.
Criminal fraud cases not involving elder abuse or embezzlement, tend to be much more policy driven. By policy driven I refer to a concerted effort by the insurance industry and the California Department of Insurance to control their health care costs.
Daniel Horowitz is the premier chiropractor defense attorney in California. His victories are legendary including the first and only MUA case to go to trial. The “MUA” (Manipulations Under Anesthesia) case was tried in Stockton, California. Had he lost that case we are informed that over 300 chiropractors would have been arrested and charged with practicing medicine without a license.
Defense of Chiropractors involves knowing the players. The cast of characters includes standard prosecution war horses such as Jennifer Martin, D.C. and James Fisher J.D.. Horowitz has confronted and challenged their scripts and exposed them to judges, arbitrators and juries as heavily biased.
The attack on the chiropractic profession is all amount money. Computer models and pencil pushers start the ball rolling so that seminars train prosecutors in formulaic attacks on chiropractic medicine. Funds flow from the insurance carriers to the California Insurance Commissioner who then rewards aggressive prosecutor’s offices with large grants.
It is shockingly simple for an honest, highly skilled chiropractor to run afoul of a computer algorithm and be targeted for investigation. If you have a working class patient population, current injuries may exacerbate prior injuries.
This creates a complex combination of symptoms that are not easily attributable to current vs. past causation. From a medical perspective this allocation of fault is usually unrelated to the treatment plan.
Medically you objectively assess the symptoms and their cause and develop the best possible plan to treat. However, if your treatment plan and frequency is compared to a patient population that has a better initial health profile, you may be flagged by the computer as “over treating.” Your allocation of fault becomes an allocation of financial liability and impacts the fight between the insurance company and your patient’s lawyer. You, as the medical professional, become a ping pong ball.
Insurance companies, the Department of Insurance, and the Chiropractic Board often considers over treatment a fraud issue. Upon referral, your patient’s bills and clinical documentation are reviewed without ever examining the patient. An assigned expert will determine whether your diagnosis, treatment plan, and actual treatment conform to chiropractic standards. See: ACA Article by Dr. Daniel Redwood.
As a prosecutor, I often received requests from the Department of Insurance to review the case for the filing of criminal charges. The SIU (Special Investigations Unit) of the insurance companies often hired retired police officers to investigate and put together reports that accompany a request for prosecution. The insurance paradigm is that in general, a few adjustments and a moderate level initial examination are all that is justified in terms of chiropractic treatment. The push is to make DC’s glorified physical therapists and to render any higher level of professional care, unjustified (meaning they won’t pay) and potentially fraudulent.
While many chiropractors refer a patient for imaging or to an orthopedist when treatment extends more than a few months, this prudent is not a guarantee of safety. Many of the physicians who accept DC referrals are “tagged” by insurance companies and subject to SIU and fraud unit scrutiny.
The Department of Insurance allocates millions of dollars to District Attorney’s Offices around the state to combat various types of insurance fraud. The allocations are often based on productivity, so It creates a self fulfilling prophecy. They need to bring prosecutions in order to get the next round of money. It is true the vast majority of referrals go to the licensing board, which creates its own set of difficulties for a practitioner. The consequences of the criminal cases go well beyond licensing board issues.
If you learn that you are under investigation, it is best to act quickly to prevent a Board Accusation or criminal charges. Remember that by the time you learn that you are under suspicion, there has already been significant investigation of the claims against you. Very rarely do these go away with a simple letter of explanation. In all cases, even those that are completely unfounded, you should seek immediate advice from an experienced medical case attorney.
Please feel free to contact me if you have questions or concerns.