On behalf of an insurer, American Claims Management was getting California workers’ compensation claims with treatment at a medical clinic outside their MPN (medical preferred network). ACM also received invoices for interpreters and suspected medical fraud.
The “injured” workers reportedly saw multiple doctors at the clinic, but the reports were inconsistent: One patient was found to be 20 pounds lighter and have different injuries than on his visit three days earlier. ACM’s adjusters referred the cases to Investigation Solutions.
IS researched the name of the medical doctor who not only held the license for the clinic but also owns and manages the clinic. The receptionist didn’t recognize that doctor’s name. Instead, she provided the name of a chiropractor, confirming he owns the clinic (that in itself is illegal). When pressed for the name of the medical doctor who runs the clinic, she asked the chiropractor. The chiropractor gave our investigator the same name that the receptionist didn’t recognize. Our investigator tried to speak with the MD at her home, but she was unavailable.
IS found prior employees who said that the office staff were paid by the interpreting company; they were not employed nor managed by the MD. The interpreting company staff took the medical histories by phone and even wrote the reports from their brief visits with chiropractors. One chiropractor told us she was directed to prescribe treatment to everyone, regardless of the outcome of the initial exam.
ACM stopped paying the clinic and interpreters, and held strong on the denials. A year later, the chiropractor that admitted owning and operating two medical clinics was criminally charged with insurance fraud. The owners of three interpreting companies plead guilty to fraud and kickbacks.
A medical clinic without an MD? Not legal. Not only did we reduce claim payments by millions of dollars, but more importantly, many injured workers were no longer targeted by these frauds.