Medhaps

Case of the Conned Cons

Posted on 23. Apr, 2010 in Case Reports

Case Synopsis

The “Accident”

On March 6, Maria visited Dr. Gray at his office and told him that her chiropractor had referred her to him. She also told Dr. Gray that her chiropractor said she was suffering from “stress and irritation” from her car accident.

However, Maria also told Dr. Gray that she wasn’t actually physically hurt by the accident, but that the chiropractor had told her that her insurance claim would be stronger if she had those symptoms. As a side note, Maria also said she was pregnant.

Unscrupulous Advice

Dr. Gray advised Maria that if anyone asked her about her insurance claim, she should refer them to her lawyer—and if anyone asked about her health, she should refer them to her doctor. He also told her to never give any information directly to the insurance company. He then coached her on how to respond to inquiries regarding her health. After all, he knew both the chiropractor and attorney and had worked with them in the past.

Another Chance

Five days later, Maria returned to Dr. Gray’s office for her physical exam. During the office visit, Dr. Gray told Maria that he was taking her case to make sure she got money from the insurance company.

Maria reminded Dr. Gray that she had not been hurt. Dr. Gray cautioned Maria that if she did not state that she had pain, then everyone (including himself, her chiropractor, and her lawyer) would be engaging in illegal activity.

View Actual Case File

Yet Another Chance

A month later, Maria had her final office visit with Dr. Gray. Again, she told him that she had not really been hurt by the car accident. She also told him that she had a miscarriage.

What an opportunity for Dr. Gray! He told her to discuss the miscarriage with her lawyer and to tell him that she lost the baby because of the stress and pain from the accident. He made sure that she would emphasize the loss of the baby because it would get her more money.

Point of No Return

On May 1, Dr. Gray submitted his medical report to Maria’s attorney. In the report, Dr. Gray reported that as a result of the car accident, Maria had sustained multiple soft tissue injuries. He listed a series of physical complaints made by Maria and stated that her outlook was “fair”. His total bill was $550.

Unfortunately for all those involved, Maria was an undercover agent in an insurance fraud sting headed by the California Department of Insurance.

Case Outcome

Dr. Gray had his license revoked but stayed with 5 years probation. He had 45 days of actual suspension.

Dr. Gray, the chiropractor, and the attorney were all criminally charged with insurance fraud.

Analysis by Jessie

Stories like this always irritate me. Such blatant disrespect for the legal system, taking advantage of someone’s injuries(or lack of in this case), and pushing for their own agenda are all very disturbing. With doctors like this in the system it’s no wonder the cost of health care keeps rising. Insurance fraud doesn’t just affect the doctor or the individuals involved. The trickle down affect hurts all of us, the consumers most of all.

I think what amazes me is exactly how persistent Dr. Gray was even after Maria repeatedly stated that she had no injuries and how he then jumped on the chance to use such a huge loss to get more money out of the lawsuit. Out of everything else, that disgusts me the most.

It’s a shame that such people exist in this profession. I’m glad that he was caught and that this wasn’t a real patient experiencing this. I’m torn on his actual punishment. While no actual physical or emotional harm came to a patient his ethics have been shown to be seriously compromised. I’m hoping with his probation are periodic checks on his actual case files and insurance claims.

Jessie's DAISE Score - What is this?

Score
4.2

Damage	Anger	Ineptitude	Shock	Ethics
0	6	1	4	10

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

The disheartening part about this story is that it is far too common. Everyone wants to take advantage of the insurance companies. What Jessie says is correct. We don’t always remember is that the costs are usually just passed down to other customers. Insurance fraud is not stealing from the insurance company, it is stealing from your fellow insured.

Please, I want everyone reading this to know that even if your lawyer or doctor tell you to lie, don’t do it! Be thorough and complete in your insurance claims, but lying is a very dangerous game to play.

Florence's DAISE Score - What is this?

Score
4.6

Damage	Anger	Ineptitude	Shock	Ethics
3	7	2	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.

Response by Lyssa

I’m trying to find a different view to write about, but the truth is, insurance fraud is very costly. It’s estimated insurance fraud costs Americans around $80 billion a year in false claims. I think it can be very tempting, especially when it’s a) very difficult to catch and b) very easy to commit a “white lie” on a claim, like pain for example.

On the other hand, one could argue Dr. Gray was looking out for the best interest of his patient and tried to help her get more money from the “big and evil” insurance company. He just happened to make a little money on the side while helping her. Even this, however, is a far fetched argument, as it is hard to consider breaking the law as sound advice when helping anyone.

Lyssa's DAISE Score - What is this?

Score
3.6

Damage	Anger	Ineptitude	Shock	Ethics
1	5	1	1	10

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: California, Fraud, Insurance, Loss of License/Stayed