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The adjustment bureau: Employee admits adding services, charging extra

9:34 PM, Sep 14, 2011   |    comments
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The claims manager's admission directly conflicts with what the owner of CHP has told 9NEWS in the past. CHP owner David McReynolds has claimed CHP does not add services to bills unless they were actually performed.

"We have to add a certain billing code to get them [CIGNA] to pay the claim," the claims manager told the patient during a phone call.

The patient, who doesn't want her name used, showed 9NEWS several explanation of benefits from CIGNA where Columbine had added an extra $61 service multiple times on different dates when her husband actually didn't receive the services.

"Why would you bill for a service that wasn't performed or done?" the patient asked. "How do you say he got an adjustment and he didn't get an adjustment? He got a trigger point on his ankle."

"That's in order to get the system to pay," the manager replied. "Basically, the two codes that were billed are basically the same codes. It's an adjustment of the spine in two different ways... your body's being adjusted. It's an adjustment."

When the patient was still confused, the manager said, "You're not in the industry, so you don't understand."

Those who do understand the industry say there is no excuse to ever change a code or increase a doctor's fee without the doctor's and patient's permission.

"Whenever you are changing provider codes, when you're changing a description of the service, there really is no justification for that. That is a big red flag that there are problems here," Dr. Joe Ramos said, a licensed medical doctor and attorney who practices medical law, said. "It would be like having your appendix removed but your health insurance doesn't cover it. So the biller says 'let's just bill this as a by-pass surgery for your heart; they cover that.' That is so far off base."

Ramos says if billing companies change codes for services, they're not only tampering with patients' billing records but also their medical records. Some insurance companies have access to databases from health insurers that show what people have been treated for, Ramos said. 

"The biller has created a disaster for people and their records," Ramos said.

CHP bills CIGNA Health and Kaiser Permanente insurance companies on behalf of some 350 chiropractors in Colorado.

A 9Wants to Know investigation found CHP receives accurate bills from chiropractors, then sometimes increases their fees or adds services that weren't performed. CHP says it always calls the chiropractors first to make sure that the extra treatment added was actually performed. Chiropractors across the board told 9NEWS that's "pure rubbish." The employee also admitted CHP adds extra services to bills in a recorded phone call with a patient.

In an hour-long sit-down interview with no cameras allowed, McReynolds told 9NEWS he has contracts with the insurers that allow him to adjust the bills. He said confidentiality agreements prevent him from showing anyone the contracts to prove it.

But expert say that's no excuse.

"To stand back and say 'we're protected' or 'we have a contract' is not good enough.  There's a legitimate concern here about changing codes, about billing services that were never provided and changing prices," Ramos said.

In a reply to 9NEWS Wednesday night, a CIGNA spokeswoman emailed that they would respond soon. Kaiser said it has a contract with CHP that's very different from other insurers.

"When our members have questions about any of their benefits, we take these matters seriously and work with them to answer their questions or address any concerns raised," Kaiser Senior Media Relations Strategist Amy Whited said.

If you have any news tips, please email investigative reporter Deborah Sherman at Deborah.Sherman@9NEWS.com.

(KUSA-TV © 2011 Multimedia Holdings Corporation)

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