Too See or Not to See
Posted on 24. Sep, 2009 in Case Reports
Case Synopsis
Not all medhaps involve actual harm. This week’s case is a tad different. Here’s what happened:
Dr. Fortuna worked for a medical group in Alabama from June 1, 2007 to November 30, 2007. His primary duty was to conduct interviews using a one or two page form to approve and recommend patients involved in automobile accidents for chiropractic treatments.
In a normal typical situation, a person involved in an accident may suffer from injuries such as back and neck pain. Usually a physician would evaluate and examine the patient to determine what may be wrong. In that process, the doctor may conclude that the patient needs chiropractic manipulations and refer appropriately. The patient then goes and finds a chiropractor who bills the insurance for the services.
Sometimes the injured person would visit the chiropractor directly without first visiting the doctor. The patient would then pay cash or have the chiropractor bill the insurance company. Some insurance companies, however, require a doctor’s referral before they would authorize or pay for chiropractic manipulations. This is often the case when it comes to automobile claims to prevent unnecessary chiropractic treatments. That’s the job that Dr. Fortuna had. Patients would be sent to him after they had seen a chiropractor for his referral. This would allow the chiropractors to continue treatment and bill the insurance company.
What’s unique in this case is that Dr. Fortuna never actually examined firsthand the patients. Instead, he would call and conduct telephone interviews, filled out a form, and recommended further treatments with the chiropractor. His documentation did not state what specific treatment was recommended nor the reasoning for making such recommendations for treatment. This was done in 100% of the time with over 150 patients.
The motivation? Dr. Fortuna was paid a retainer fee and a per patient fee for such referrals.
Case Outcome
Dr. Fortuna had his license revoked.
Analysis by Lyssa
Well, a short but informative case this week. Compared to the previous cases, it might even seem rather tame. However, it does bring up a few good points. It’s people like Dr. Fortuna that helps drive up the cost of insurance premiums for everyone. Many of his “patients” probably didn’t need to see a chiropractor. However, because of Dr. Fortuna’s referrals, he was basically approving unnecessary procedures to be done, driving up healthcare costs for everyone.
I’m curious about how he was caught, though. It seems like his patients wouldn’t report him for helping them out. Anyways, in the end, it’s a very simple case, in my opinion. He lied, got caught somehow, and paid the consequences. Luckily, no one was hurt or injured because of his unethical practices.
| Score |
|---|
| 4.2 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 1 | 4 | 5 | 3 | 8 |
Response by Florence
Indeed, this is a very simple case. It is so very sad to find professionals who are supposed to want to “help people” end up breaking the law and code of ethics in the name of greed. It used to be that doctors were people we could look up to as ones with higher education and wisdom, as someone we could trust. This case shows that doctors simply are not above making some easy money for themselves if they can. At least Dr. Fortuna didn’t actually do harm to his patients, either purposefully or not, like some of the other doctors we have covered so far.
| Score |
|---|
| 3 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 1 | 2 | 4 | 2 | 6 |
Response by Marc
Whoa, I disagree with both of you actually. I think this case is rather complex. 150 patients is not a small number. This case isn’t just about lying, but outright fraud. Dr. Fortuna set up (or at least worked in) a system created to steal. First off, Dr. Fortuna stole from insurance companies. While many of us aren’t overly fond of insurance companies, they do have a duty to carefully disperse funds appropriately. By claiming funds that don’t belong to him, Dr. Fortuna got paid for services he never actually rendered.
Secondly, Dr. Fortuna stole from his fellow physicians. By diminishing the funds available to the insurance companies, he effectively decreased the ability for them to pay other doctors for services that were actually provided. Hard-working doctors were cheated of their money because there were less to go around.
Thirdly, he stole from patients. Sure, the patients had pain and muscle spasms—but that doesn’t mean they need chiropractic treatment. Without examining the patient, there’s no way for him to know if they have other problems that could perhaps require surgery or other treatments.
That’s just my two cents.
| Score |
|---|
| 5.2 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 2 | 5 | 5 | 6 | 8 |
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What_the_heck
Oct 2nd, 2009
I’ve heard of pulling a fast one but this guy really had it down-pat! What I don’t understand is how can the patients not question the fact of being directly reffered from this doctor without them first going to see him? Also I’m not a huge fan of the insurance companies and some of their practices but this type of doctor is why the insurance companies unfortunately have to be the way they are. It’s bad enough when a patient tries to cheat the system but when a doctor – someone we have been taught to trust and know they will help us – does this it is really inexcusable. This doctor not only took the money but in-kind also showed his uncaring mentality for the sick and infirmed.