Medhaps

Double Dipping Dope

Posted on 11. Nov, 2009 in Case Reports

Case Synopsis

If you’re a surgeon performing cosmetic surgery in Southern California, you can make good money—especially if you were featured on Dr. 90210. It can be even better money when you bill both the insurance company AND your patient at the same time. Dr. Harrold, a board-certified OB/GYN, thought this was an excellent idea, but he forgot about one important rule when it comes to these things: don’t get caught.

Ashley

Ashley was a 32 year old actress when she began seeing Dr. Harrold in 1996 because she had pelvic pain along with very painful menstrual periods. According to bills he sent Ashley’s insurance company, Dr. Harrold stated he performed two comprehensive examinations, including obtaining a complete medical, menstrual, and pregnancy history, pap smears, and ultrasound. Oddly, there is no evidence that any of these were done. He also noted that she had anemia although the lab reported no normal blood levels. In his notes, Dr. Harrold wrote that she had no previous surgery when in reality she had knee surgery in the past.

Making 1 Become 2

For Ashley’s pelvic pain, Dr. Harrold scheduled her for surgery. Subsequently, he billed the insurance company for a hospital surgery visit, even though it was actually done at his office. He performed a laparoscopy as well as liposuction in the same session under the same general anesthesia, although he dictated them as if they were two different surgeries. He also claimed he was assisted by another physician during surgery, which was again false. Within his report to the insurance company, he left out the liposuction part and “unbundled” the laparoscopy into 6 different “procedures”, two of which were “exploratory laparoscopy” and “peritoneoscopy,” synonymous terms.

Unbundling is when one procedure is dissected into multiple smaller procedures so that more can be billed. It’s like if your son orders a pizza and then you get a bill for the pizza, along with a bill for the flour, toppings, and cheese—and then a bill for the milk to make the cheese.

Dr. Harrold billed the insurance company more than $10,000 for just these two procedures.

View Actual Case File

Double-Dipping

Dr. Harrold then scheduled 3 post-operative visits with Ashley, billing the insurance company for each one. Post-operative visits are usually not billable since the fees were included with the procedure itself. In addition, his bills failed to mention the liposuction, knowing full well that the insurance company would pay far less if they knew liposuction was part of the same surgery session. In the end, Ashley paid Dr. Harrold $3,500 out of pocket for the “liposuction part” of the surgery. This was not the first time Dr. Harrold had done this.

Trisha

The funny thing is, six months earlier, a fashion model named Trisha came to see Dr. Harrold. On reports to her insurance company (coincidentally, Ashley and Trisha both had the same insurance), Dr. Harrold documented almost the same exact conditions, events, and procedures as in Ashley’s case. Unfortunately for Dr. Harrold, he didn’t bother explaining to Trisha what he was doing. So when the insurance company contacted Trisha regarding her “claims,” she went ahead and wrote them that she had paid for the liposuction in full—that “no claims need be processed.” Well, that was news to the insurance company!

It All Falls Apart

Trisha also told an investigator afterward that she had never experienced pelvic pains. She went to see Dr. Harrold only for liposuction. When Dr. Harrold learned of what Trisha had said, he was very angry and refused to continue to treat her as a patient. To her dismay, when she inquired as to what she was supposed to tell the insurance company, he wrote “pelvic pain” on a piece of paper and showed it to her.

Case Outcome

Dr. Harrold’s licence was revoked, but stayed (meaning he was allowed to keep his license) with 4 years probation.

Analysis by Marc

You just gotta love it when a doctor starts blaming the patient for messing up his crime. Then, he gets upset when she refuses to cooperate. What nerve she has for ruining his brilliant plan! All joking aside, there’s really no doubt that Dr. Harrold planned to cheat the system and double bill. The curious thing is why there were only two patients detailed in the report. You would think a doctor with an insurance fraud scheme would have done this more often than twice in his career.

In terms of damage to the patients, there was little done to harm them. In fact, they probably benefited from the cheaper rates! It is hard to say that the doctor was in any way inept, except that he was caught in his little scheme. Regardless of whether this was surprising or not, he definitely breached the code of ethics by “upcoding” and “unbundling.” Unfortunately, the fact that he still runs a successful practice (not in the report, just some further research I did) shows that not many people care about acts such as these…or more likely it’s perhaps they just don’t know better….

Marc's DAISE Score - What is this?

Score
3.8

Damage	Anger	Ineptitude	Shock	Ethics
1	4	2	4	8

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Response by Florence

I think it’s so horrible that Dr. Harrold would get so upset with Trisha for doing the right thing and telling the truth. This is a doctor that told his patient to lie! I could in no way respect a doctor such as that. No amount of re-education or probation is going to change something like that. He knew what he was doing was wrong. It was not a case of misunderstanding. It seems that people do not care so much about defrauding insurance companies like that. Unfortunately, I think these play a role in the ever-increasing health care costs we have now.

I also think it is curious that there were only 2 cases cited, but it is possible the Board was unable to prove any other cases they may have uncovered and decided to just get him on those two instead. That is not uncommon practice, I believe.

Florence's DAISE Score - What is this?

Score
4.6

Damage	Anger	Ineptitude	Shock	Ethics
2	3	2	7	9

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Response by Jessie

It’s frustrating to me when someone’s greed overrides their sense of responsibility. Even more so, when it’s a doctor. I don’t see that any actual harm came to either patient, it’s still very disturbing that he lied about their medical conditions. I’m not surprised with his reaction to Trisha, he knew he was caught and had to be mad at someone. Of course taking personal responsibility was out of the question. I’m also surprised that other charges weren’t brought against him for the insurance fraud.

I agree that this is probably a piece of why insurance rates keep rising. I also think the reason people don’t take this as seriously is because they don’t look at the fraud as having hurt an individual, just a company. I was surprised too that only two cases were brought to the board’s attention. Maybe he got over confident and sloppy. It could also be that because these two patients had the same insurance company making it easier to prove. Either way, I have a feeling he’s done it more than these two times.

Jessie's DAISE Score - What is this?

Score
3.4

Damage	Anger	Ineptitude	Shock	Ethics
1	4	1	2	9

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Tags: Featured, Loss of License/Stayed