In a late October 2008 tele-conference with state and insurance investigators an executive from a southern state chiropractic association with twenty years of chiropractic experience reported that most of the fraud committed by chiropractors is perpetrated by chiropractors employed in clinics owned and operated by non-chiropractors.


This executive went on to report that lay-owned clinics account for 80–90% of the chiropractic fraud problem, and that these non-chiropractors prey on chiropractors just out of school saddled with large student loan debt who will do whatever they are told.


Has this executive found the answer to successfully combating chiropractic fraud – prohibiting lay ownership of chiropractic practices?


Well, the answer is a resounding NO!


•The chiropractic regulatory board in this southern state indicates that there is no evidence to support the executive’s assertion that lay-owned chiropractic clinics account for most of the fraud committed by chiropractors.


•Numerous states do not allow for non-chiropractors to own chiropractic clinics and these states have found that they are not immune from chiropractic fraud.


•Chiropractors saddled with large student loan debt inclined to engage in unlawful activity to pay their bills are just not only employed in lay-owned clinics but are employed in clinics owned and operated by other chiropractors, as well as running their own practice.


In this southern state it is clear that the chiropractic association has an agenda to rid the state of competition posed by successful lay-owned chiropractic clinics, and appears their representatives will say anything to champion their cause.


I suspect that health care consumers in this southern state are far less concerned about who owns the chiropractic clinics then they are about quality of care issues brought on by chiropractors not being required to be on premises to supervise non-licensed staff administering health care services, and chiropractors delegating the administration of provider services to non-providers.

I read with interest the article in the September 2008 edition of The American Chiropractor titled “Deal with Investigators from a Position of Strength” written by a chiropractor in the Minneapolis-St Paul area reporting he offered the article as an illustration of how a strong and reasoned approach based on solid coding and documentation, coupled with a willingness to listen, can help doctors hold the line against contested claims and develop positive relational experiences with payer personnel.


The author's actions would do little to facilitate a position of strength, with either Farmers or any other insurance carrier. The article, in my opinion, fails to live up to its title. From my perspective, as an investigator, I would suggest the title, “How to Paint a Target on a Provider's Back.”


Any goodwill the author may have developed with the Farmers investigator was likely dissipated by his article. Rather than holding-the-line, the author proposed a compromising course of action:


1. He does not meet with investigators or lawyers! Knowing when and when not to meet with investigators and lawyers is critical determinant! Experience has shown that, under the right circumstances, providers who meet with claims-handlers and fraud-investigators to discuss genuine concerns regarding submitted claims are able to communicate more effectively regarding what the provider did, why the provider did it, etc. Such discussions frequently resolve any issues or misunderstandings regarding clinical and billing activity. Additionally, such meetings frequently facilitate payment. An across-the-board refusal to meet with investigators is a red-flag to investigators, suggesting that the provider is hiding something. Heightened suspicion may entice more in-depth and expanded investigations.


2. He does not use (non-weight bearing) x-rays taken by other health care providers! He may soon be faced with questions from investigators on this activity, including: Has he ever not taken x-rays and used existing x-rays for patients who had limited or no chiropractic coverage (e.g., Medicare, cash)? If so, why not in the instance investigated? Does he request and review the x-rays taken elsewhere immediately after an accident? If not, why not?


3. He purports to bill $200 per visit when performing therapy codes for around five minutes each, billing each service at $50 knowing they were billed in excessive amounts! Could this chiropractor be faced with future questions as to the clinical relevance of therapy services administered only for five minutes; is the billing of multiple units of time-based therapies not administered for 15 minutes consistent with correct coding conventions; should such activity have been billed by reporting only one unit of the primary therapy administered?


4. He documents the care being given to patients on the HCFA 1500 claim form! Health care services are not documented on claim forms. Further, the claim form is CMS 1500 not HCFA 1500 and has been for years. Could this simple misstep be used by investigators to infer that the provider does not have a strong understanding of the laws & rules?


5. He reports the fraud investigator from Farmers Insurance indicated that Farmers should send more of their clients to him! I suspect that Farmers Insurance, after their review of the article, will want to examine this claim very closely. In my many years of working around the Insurance and Health Care Professions, I have never heard of an insurance company investigator referring to an insured or a claimant as “client”.


Is the article analogous to bringing a knife to a gun-fight? The author indicates that he credits a consulting group with strengthening his practice and resolve in maintaining his position under challenge. It would be quite interesting to review the consultant’s response to the author's advice. Whether the consultant responds is irrelevant. The author's position is likely to be put to the test very soon!


Click the related link below to read the chiropractors article.

In response to my article "National Insurance Fraud Seminar Focuses On Chiropractic" published 11/17/03 in Dynamic Chiropractic, Paul Lee, P.T. aka quackbuster writes in his blog -


This article by a chiropractor is an unsurprising and typical example of how chiropractic and chiropractors ignore the elephant in their own living room. To everyone else, it's a "so what else is new" experience, when one reads about the attitudes of the insurance industry people. Of course they are skeptical about chiropractic. What else can one expect when the profession fails to police itself, and even teaches attitudes and practices that all others in the healthcare field consider unscientific and unethical?


The problem with what he writes is problematic on a number of levels:


1. I wrote the article and I am not a chiropractor, thus it is not a typical example of how chiropractic and chiropractors ignore the problem, or in his words "the elephant in their own living room".


2. It appears that he failed to read the article before placing it on his blog with his tainted remarks.


3. The purpose of my article was to point out the inaccuracies of information being taught to insurance investigators at the seminar.


Mr. Lee appears to be indicative of the problem that we all face today in health care - which is that investigators, and in this case, a self-proclaimed quackbuster, choose to ignore the available information, relevant evidence and facts prior to spewing their venom and hate.


Surely, if Mr. Lee had read the article he might have learned something.


Click on the related link below to read my article.

It’s no secret for today’s health care provider that investigators from regulatory boards, insurance companies and law enforcement agencies are on the prowl looking for providers who are not following the laws & rules – with a major focus on health care fraud!


And, these investigators, especially law enforcers, are particularly interested in finding health care providers engaged in health care fraud and establishing the evidence to prosecute providers who 1) billed for services not rendered; 2) billed for services that misrepresent the nature of the services provided; 3) billed for substandard and/or unnecessary services; and/or 4) billed for services that misrepresent the actual service provider.


Law enforcement agencies, even the Fed’s, have limited resources that prohibit them from investigating every provider on whom they receive information alleging health care fraud.


How do fraud investigators maximize their resources, and enhance probabilities for successful health care fraud prosecutions? They search for easy targets!


They don’t have to search far! What is an easy target you ask?



Click on related link below for the 9 Biggest Mistakes.

In the late 1990’s, the government, via well publicized news releases, requested that “ALL” health care providers implement health care compliance programs as a means to self-police themselves to ensure compliance with health care laws and rules, as well as to facilitate detection and correction of identified misconduct. This request was made in conjunction with the governments increased focus on combating health care fraud, that was greatly enhanced by the passage of the Health Insurance Portability & Accountability Act of 1996 (HIPAA).


Unfortunately, when most health care providers hear “HIPAA” they think of patient confidentiality and record security, but not the most significant aspect of this law - the expanded ability of the federal government to combat health care fraud and abuse, including:


For more on this topic click on related link below.