When The Undercover Agent Comes To Your Office

What Brought Him Here ... What He's Looking For

By Editorial Staff

The following information is taken from documentation pertaining to the Oregon Workers' Compensation lawsuits. This documentation includes the an actual affidavit for a search warrant used in the investigation.


Suspicion. There is an estimated five to seven BILLION dollars of health fraud occurring in the U.S. every year. You can't blame the insurance companies or the workers' compensation people from trying to eliminate it.

Clearly, the trend towards the prevention of insurance abuse has begun. From accross the country comes the word that many insurance companies are sending in "undercover patients" to investigate various suspicions of violations.

Specifically, there are a number of events that are the most common causes of an investigation:

  1. A complaint. If a patient actually complains about the bill, that will cause the company to respond. This complaint would usually cite treatment billed for, but not received.

  2. Overbilling or failing to refund over-payments. This is information that is kept in the computer. The computers can very easily print out a "hunting license" on any doctors who are guilty of this practice.

  3. "One-size-fits-all" treatment schedule. This is also a practice that is easily reported by the computer. It can be the basis for an overutilization investigation.

  4. Poor or no documentation. Obviously, if you don't communicate, you raise suspicion.


When the undercover patient comes into your office, they are there for one reason: Probe every area of your practice in order to discover violations. They aren't paid to come up empty-handed.

In the case of workman's compensation investigations, the first priority is to determine if the doctor will file a claim as workers' compensation knowing that the injury didn't occur on the job. Based on the affidavit, these undercover agents are very patient. They may take four to six visits before they make their move.

The usual routine is to tell the doctor on the initial visit that the injury occurred at home. When the DC becomes comfortable with their relationship (and the income) the "patient" will tell the doctor that he "told his boss he did it on the job."

This is the point where the doctor has to decide. If he acquiesces, he's guilty. The DC must refuse to go along with the fraud. Those who decide to rework patient files and put in workers' compensation claims could be charged with first degree theft.

Other possible items on the undercover patient's agenda are:

Billing the insurance company more than the general public: this includes N.O.P.E. and discounts as well as renting or selling insurance patients theraputic equipment not prescibed to non-insurance patients.

Overpayments: keeping overpayments instead of returning them. Poor recordkeeping is no excuse. This includes "no-show" billing as well.

Double billing: billing two insurance companies for the same treatment.

Overutilization: in the case of one of the chiropractors arrested in Oregon, the undercover patient testifies that the DC involved "advised that these type of injuries generally heal in three (3) or four (4) visits." After this patient's case was converted to a workers' compensation claim, the undercover patient received twenty treatments before the patient ended the care.

It is most unfortunate that this kind of situation exists. Your job is to insure that you are practicing in a manner that will withstand constant scrutiny. Only then will we exonerate the chiropractic profession and force the insurance companies to deal with the real abusers.

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