Bill Clinton was once quoted as saying, “There will always be bad guys out there in the world who will try to take advantage of people’s vulnerabilities.” Was he referring to dishonest doctors and unsuspecting international students when he made that comment? According to the Washington State Department of Health Medical Quality Assurance Commission, this is a story of "unprofessional conduct" that dates back to 1999 when a doctor in Washington state acquired his license.
It was right at this time that The Lewer Agency’s claims team first started receiving calls from the doctor, an ophthalmologist, who said that Lewer was not paying claims correctly. Many of the claims involved international students attending North Seattle Community College, a LewerMark client. After a number of “odd” claims were presented to The Lewer Agency for payment, claims manager Patti Dennell and her deputy, Karen Powell, began to get suspicious.
“This doctor is one that both Karen and I had uneasy feelings about as far back as 7 or 8 years ago,” Patti explained. “The first clue was when he was contracted with PHCS. When we paid the claim, adjusting for the PHCS discount, he called and said that he didn’t know which network discount was being used, and that we accounted for too large of a discount. He stated that if he would have known which discount was being used he would have charged a ‘different’ rate, meaning a higher rate.
“It was about this time that he removed himself from the networks,” Patti continued. “He then started seeing our students on a very regular basis. He would diagnose each student with the exact same condition, and then he would treat each student with the same exact procedure – tear duct plugs – over and over again, sometimes as often as once every few weeks. When we questioned him about his practices, he said that he was having trouble fitting the correct size tear duct plugs for his patients. We didn’t understand how a trained doctor could have troubles like these, not just occasionally, but consistently.
“The Lewer Agency then decided to start requesting medical records for each treatment,” said Patti. “We asked Great West Health to review each claim to make sure that the procedure being charged was medically necessary.” And, according to Patti, this is when the story gets darker...
With help from reinforcements from Great West Health, Patti learned that the doctor was a one man show out in Washington with a special interest in international students.
“He answered his own phone and did his own billing,” said Patti. “After Great West reviewed his bills, they confirmed that he was, indeed, billing for unnecessary charges and using incorrect procedure codes. Typically, a medical biller is trained to understand procedure codes, and this doctor did not have that training. Great West sent us a summary of the unnecessary charges. They also took the time to let us know which charges could possibly be paid if the doctor would have used the correct procedure code. We paid the claims according to Great West’s recommendations, and even suggested to the doctor that he rebill some of the excluded charges using the correct procedure codes. He refused to do so, and we soon discovered that he started billing the students for the unpaid charges.”
“We started requesting medical records from him,” Patti reported. “And so he would have each patient come in and sign a release form authorizing him to release the records to us. One of the students called Lewer and questioned a bill that we paid. She told us that the only reason she had stopped by his office on the date of treatment shown on the bill was to sign the medical release form he had asked her to sign. While she was there to sign the form, he asked her how her eyes were doing, and she said her eyes were fine. He then asked her if he could take a look at her eyes. She later discovered, as did we, that this ‘taking a look’ led to a claim for an office visit charge and the insertion of new tear duct plugs.
“The student went to see our contact, Jo Scozzafava, International Programs Advisor at North Seattle Community College about the bill, whom we had already contacted about this situation. Shortly after Jo’s visit with the student, she called us and asked if we were on board with her plan to assist the student and her with filing a statement of charges to the Washington Health Department, which was filed in December 2007.
The Health Services Consultant of the Medical Quality Assurance Commission in Washington then investigated the case and discovered that in 2003, the doctor saw another 19-year old patient for eye pain and blurred vision. The student was myopic and wore contact lenses. She was diagnosed with infectious keratitis and blepharoconjunctivitis and continued treatment, resulting in 45 visits over a period of 30 months. During this period, the doctor performed repeated tests and provided treatment that was not justified by the patient’s condition. No one at Lewer was too surprised when after the investigation, it was discovered that the doctor was not board certified.
“Anytime a school is willing to get involved in this manner, we are grateful,” said Patti. “The student, who came to the U.S. to attend school, was a little hesitant, but Jo encouraged her, assisted her with the process, and stayed involved until the end.”
As a result of Jo’s persistency in calling attention to this matter, the student’s (and victim’s) cooperation, and Patti’s ongoing communication with Jo throughout the process, the matter was ultimately brought before the Washington Department of Health Medical Quality Assurance Commission which found that the doctor "committed unprofessional conduct." His license expired on July 28, 2008.
Because his license is currently expired, there was no current action by the Commission which has imposed restrictions on the doctor should he attempt to reinstate his license. To renew or reinstate his license, he must petition the Commission for approval, appear before the Commission, complete a two-day ethics course, complete a minimum of 25 hours of continuing education in the area of diagnosis and treatment of eye disease, and he must pay a fine of $1,000. Further, the Commission has sole authority to grant or deny the doctor's petition for reinstatement and, if accepted, the Commission may impose any additional conditions and/or restrictions as it sees fit.
“This was a very long and drawn-out issue,” said Patti. “There was more than one occasion that this doctor called screaming and cussing at our customer service reps. He was very demanding and an unpleasant man. It really is a relief to know that we will no longer have to deal with him!”
In a thank you note to Jo this week, Jeff Crawford expressed his appreciation and indicated that due to the fact that, as Bill Clinton states it, “there will always be bad guys out there,” Lewer and its client schools must be vigilant.
"We appreciate your assistance and time with this important situation,” Jeff wrote Jo. “Unfortunately, the international students can be an easy target for this type of activity. We will be publicizing this situation soon to all of our client schools to let them know that we all must be observant of potential malpractice in our communities. When we work together, we can provide a quality and consistent program to the international students in Seattle and around the country. Thanks again for your support.”