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Health Insurance Use Wordplay to Deceive Providers and Patients

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Huntington Beach, Calif., February 26, 2023 – Insurance verification is a critical step in the healthcare industry that ensures healthcare providers receive payment for services rendered to patients. The process involves verifying a patient’s insurance coverage and benefits with their insurance provider.

The initial step is to confirm that the patient’s insurance information is correct. Once the insurance information is confirmed, the healthcare provider checks the patient’s eligibility for the services they are seeking. This includes checking the patient’s policy coverage, deductible, co-pay, and co-insurance. If the healthcare provider is out-of-network, the provider and facility obtain authorization from the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) or RC (Reasonable and Customary) rate. Based on the UCR or RC rate provided by the insurance, the out-of-network provider, facility and patient understand how much the insurance company will reimburse if they are to proceed.

This is when insurance companies use wordplay to deceive out-of-network providers and patients. They develop terminology to define what their reimbursement rate will be by replacing standard terms like UCR and RC with “MNRP (Maximum Non-Network Reimbursement Plan)” and “California Fee Schedule Rates” or “Official Medical Fee Schedule (OMFS)” to confuse patients and providers. Most patients, let alone medical providers, will not understand what this means unless they read the fine print. This information is also not shared when providers obtain authorization over the phone from insurance companies. Their reasoning is, “don’t ask, don’t tell.”

So to be clear about what the reimbursement of an out-of-network procedure will be, out-of-network providers must ask the following questions:

1)     Will you pay according to the UCR / RC rate?

2)     What percentage will the Provider get paid?

3)     Will the plan pay according to benefits to the out-of-network provider?

4)     What is the patient’s copay and deductible?

5)     Will you be paying based on the Medicare rate?

6)     What is your reimbursement rate based on; UCR, RC, Medicare, MNRP, California Fee Schedule, or OMFS rate?

7)     What is the percentage of the “UCR, RC, Medicare, MNRP, California Fee Schedule, or OMFS” rate you are paying?

Most providers ask questions 1-4 but if providers do not ask the follow-up questions 5-7, they will realize that they were deceived. 

So what does MNRP, California Fee Schedule Rate, or OMFS mean? It means that if the provider is out-of-network, the insurance company is reimbursing them based on a percentage of Medicare rate and not the UCR or RC. 

How will that affect the patient? If a patient purchases a PPO plan so that they can go to any nationwide provider or specialist and goes to an out-of-network provider, the insurance company will only pay MNRP (Maximum Non-Network Reimbursement Plan), California Fee Schedule Rates, or Official Medical Fee Schedule (OMFS), basically Medicare Rate. Insurance companies do not disclose this to patients and don’t want to disclose it to out-of-network providers, fearing the provider will decline the service. If this is the case, the out-of-network provider will not want to perform the procedure.

On the other hand, if the out-of-network provider proceeds with the procedure based on good faith and only receives reimbursement comparable to Medicare rate, the patient has to absorb the remaining balance. Either way, the patient is screwed and was cheated by the insurance company. The patient was deceived by the insurance company when they purchased the PPO plan believing that they will be covered when they see a specialist for their treatment, but in the end, they are left with more out-of-pocket costs than they had expected.

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FBI INVESTIGATORS ARE CREATING CRIMINALS

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Dr. Robert Joseph, a podiatrist in California, who was indicted by the United States District Court for the Central District of California for the illegal practice of colluding with pharmaceutical marketers for writing prescriptions of compounding drugs, is now working undercover for the FBI. In exchange for a lower sentence due to his indictment in 2018, Dr. Robert Joseph is now working undercover to deceive medical facilities and doctors by intentionally offering illegal deals.

This article is to help warn medical facilities and doctors of the devious practice that the FBI is taking to catch them in the act. It is one thing to investigate incidences due to patient complaints or whistleblowers but to intentionally embed a mole to create a problem when there is no problem, this is how the FBI works. If Adam is tempted by the apple because it was offered is that the same as if he had already bit the apple without the temptation created by Eve? In this case, the FBI is going fishing in hopes of finding something.

A medical facility in Huntington Beach, CA was a victim of Dr. Robert Joseph and the FBI. Dr. Joseph came into the facility wearing a concealed camera and had the intention of catching them by offering an illegal deal. Fortunately, this medical facility did not take the bait but wanted to share their experience with the public so that other medical offices and doctors will be aware of Dr. Robert Joseph.

As the public, we want doctors to care about us and to do what’s best for us and not be greedy. That is the oath they take when they become doctors. There are doctors who are tempted to sway but being tempted versus actually acting on greed is not the same. What the FBI is doing is turning the tempted into greedy criminals. 

Ref: https://www.justice.gov/file/1076086/download

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$150 CÓ ĐÁNG VỚI RỦI RO LÀM HẠI GƯƠNG MẶT CỦA BẠN KHÔNG?

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 Các phương pháp điều trị da bất hợp pháp đang được cung cấp trong các nơi chăm sóc da mặt và tiệm cắt tóc như được phát hiện bởi các cuộc điều tra bí mật gần đây về các nơi chăm sóc da mặt và tiệm cắt tóc ở Nam California. Đàn ông và phụ nữ đang trả 150 đô la cho mỗi lần khám cho các phương pháp điều trị bằng tế bào gốc, vi kim và collagen của các chuyên gia thẩm mỹ không được cấp phép hành nghề y tế. Tất cả những nơi chăm sóc da mặt và tiệm cắt tóc nói rằng họ có y tá và bác sĩ trong đội ngũ nhân viên nhưng các quy trình thực sự được thực hiện bởi các chuyên gia thẩm mỹ không có bằng hành nghề y này. Họ quảng cáo cung cấp tế bào gốc, collagen, vi kim để tiêm Vitamin C, PRP (Platelet-Rich Plasma) injections và phương pháp điều trị bằng laser IPL cũng như các quy trình làm đầy, botox, dùng kim để nặn mụn và mài da siêu nhỏ. Tất cả các quy trình này đều đi dưới bề mặt da và xâm lấn, vì vậy chúng cần có giấy phép hành nghề y tế và phải được y tá hoặc bác sĩ thực hiện. Hội đồng Nghề Làm tóc & Thẩm mỹ Tiểu bang không cho phép các chuyên viên thẩm mỹ và chuyên gia thẩm mỹ tham gia vào bất kỳ thủ thuật xâm lấn nào. Chúng chỉ được phép hoạt động trên bề mặt da. 

Khách hàng thường nhầm lẫn các dịch vụ thẩm mỹ xâm lấn này với các dịch vụ hoặc sản phẩm chăm sóc da mặt và biểu bì. Ví dụ, một loại kem dưỡng da có thể quảng cáo rằng nó làm mịn và đẹp da của bạn (dùng trong mỹ phẩm), tuy nhiên, nếu nó quảng cáo rằng nó sẽ chữa khỏi hoặc điều trị mụn trứng cá, thì đó có thể được coi là hành nghề y. Một chiếc máy có thể quảng cáo rằng nó hỗ trợ thẩm thấu các chất dưỡng ẩm, dưỡng ẩm để làm đẹp làn da của bạn (dùng trong mỹ phẩm), tuy nhiên, nếu nó tuyên bố sẽ giảm cellulite hoặc kiểm soát cơn đau, thì đây được coi là một phương pháp hành nghề y. Một chất lột da có thể quảng cáo rằng việc sử dụng nó sẽ loại bỏ các tế bào da chết không mong muốn và thúc đẩy làn da sáng, đầy sức sống (dùng trong mỹ phẩm), tuy nhiên, nếu chất lột da tuyên bố loại bỏ các đốm nâu hoặc sẹo, thì đó có thể được coi là hành nghề y học. Người tiêu dùng cũng nên biết ai đang thực hiện các thủ tục này. Ngay cả khi họ có treo giấy phép của y tá hoặc bác sĩ tại doanh nghiệp, hãy yêu cầu cá nhân thực hiện dịch vụ trình ra giấy phép hành nghề y của họ và đảm bảo rằng đó là giấy phép được cấp bởi Bộ y tế chứ không chỉ là Giấy phép của Hội đồng Nghề làm tóc & Thẩm mỹ của Tiểu bang. 

Với $150, khách hàng đang tự đặt mình vào rủi ro và các quy trình hoặc sản phẩm này sẽ gây ra tổn thương vĩnh viễn nếu không được thực hiện bởi những người hành nghề y được cấp phép bởi Bộ y tế. Nếu người tiêu dùng phát hiện ra rằng một hành vi bất hợp pháp đang diễn ra, hãy báo cáo các hoạt động này cho Hội đồng Nghề Làm tóc & Thẩm mỹ Tiểu bang tại www.breeze.ca.gov


IS $150 WORTH THE RISK OF DAMAGING YOUR FACE?

 Illegal skin treatments are being offered in beauty salons as discovered by recent undercover investigations of salons in Southern California. Men and women are paying $150 per visit for stem cells,  micro-needling, and collagen treatments by estheticians and cosmetologists that are not medically licensed. These salons say they have nurses and physicians on staff but the procedures are actually done by estheticians and cosmetologists. They advertise offering stem cells, collagen,  micro-needling to inject Vitamin C, PRP (Platelet-Rich Plasma) injections, and IPL laser treatments as well as fillers, botox,  extractions, and microdermabrasion procedures. All of these procedures go below the surface of the skin and are invasive, so they require a medical license and must be administered by a nurse or physician.  The State Board of Barbering & Cosmetology does not allow cosmetologists and estheticians to engage in any invasive procedures. They are only allowed to work on the surface of the skin. 

Customers often mistake these invasive cosmetic services for facials and epidermal services or products. For example, a skin cream can advertise that it smooths and beautifies your skin (cosmetic use), however, if it advertises that it will cure or treat acne, it could be considered the practice of medicine. A machine could advertise that it assists in the penetration of hydrating moisturizers for the beautification of your skin (cosmetic use), however, if it claims to reduce cellulite or manage pain, this is considered a practice of medicine. A skin peeling agent could advertise that its use will remove unwanted dead skin cells and promote vibrant, glowing skin (cosmetic use), however, if the skin peeling agent claims to remove brown spots or scarring, it could be considered the practice of medicine. Consumers should be aware of who is performing these procedures as well. Even if they have a nurse or doctor’s license posted at the business, ask the individual performing the service for their license and make sure that it is a medical license and not just a State Board of Barbering & Cosmetology License. 

For $150, customers are putting themselves at risk and these procedures or products cause permanent damage if not done correctly by some with a medical license. If a consumer discovers that an illegal practice is taking place, report these activities to the State Board of Barbering & Cosmetology at  www.breeze.ca.gov 

Ref: https://www.barbercosmo.ca.gov/forms_pubs/publications/skin_device.pdf

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Insurance Companies are Being Sued by a Surgery Center that Had Enough

After being owed over $6M, Coast Surgery Center has had enough and is suing the insurance companies.

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NEWS PROVIDED BY Yahoo News

Jan 16, 2023, 06:35 ET


HUNTINGTON BEACH, Calif., Jan. 16, 2023 /PRNewswire/ — Coast Surgery Center is an outpatient surgery center in the city of Huntington Beach, CA and has been in business since 2018. Coast is a facility for outpatient procedures offering healthcare related services. Just like most medical facilities, before services are rendered to a patient, the provider and facility obtain authorization with the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) rate for the procedure. Based on the UCR rate provided by the insurance, the provider and patient understand that if they are to proceed, how much the insurance company will reimburse. All the information obtained is documented by both the insurance carrier and facility as a part of their policy and practice.

Coast provides services to its patients relying on the insurance representations solely based on their statements, promises, and representations. By authorizing a procedure, insurance companies are granting Coast to provide healthcare services to their members, and Coast is fulfilling the insurances’ contractual obligations to its members.

The insurance companies significantly started reducing the reimbursement rate from UCR to below Medicare rate in 2018, and for some claims, they didn’t pay at all. Since 2019, Coast Surgery Center accumulated bills totaling over $6M. So now Coast is suing some of the largest health insurance providers in the country; United Health Care, Cigna, Aetna, Anthem Blue Cross of California, Blue Shield of California, Blue Cross Blue Shield Associates, and all Blue Cross Blue Shield affiliated companies for illegal, coercive, unfair, fraudulent practices, bad faith and deceptive advertisements.

In the civil case #30-2022-01271476-CU-CO-CJC filed by Coast Surgery Center in Orange County, California, Coast states they billed Blue Cross $49,550 for a surgery and Blue Cross paid $202.99. This is an example for many of the underpaid bills. Insurance companies have had a history of lawsuits for underpaying. As of June 30, 2019, 43% of Anthem’s medical bills were unpaid. By 2021, that figure rose to 53%, resulting in a total of $2.5 billion unpaid bills. Yet, Anthem’s profits in 2020 were reported to be $4.6 billion and $3.5 billion in the first half of 2021.

These unpaid bills harm medical providers like Coast by failing to provide reasonable rates for its services, negatively impacting the quality of service, value of Coast, and significantly impacting Coast’s business relationship with patients and prospects. With this lawsuit, Coast is hoping that the big insurance companies will stop taking advantage of small providers as Coast will continue to provide critical, quality healthcare services and treatment to its Defendants’ members on its behalf and hope to be paid reasonable rates.

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