I would like to bring to your attention and ask that you thoroughly investigate an attempt by a mega health care provider in the Commonwealth of Massachusetts to deny my wife’s Medicare and Supplemental Health Insurance benefits, and compel me to make the “full” payment for the emergency doctor services my wife received from Holy Family Hospital in Methuen, MA which is managed by Stewart Healthcare System, one of the mega health care providers that appear to have near monopoly control over health care in many areas of the country including the greater Boston Area. Compelling me to make the full payments allows them to collect and pocket the Medicare discounts while I pay for both the Medicare discount and Medicare payment. In this case they were trying to compel me to pay over $400 when if properly processed my co-pay would be around $25. While my immediate claim appears to have been resolved with the assistance for Eastern Massachusetts, Maine, Vermont, and Rhode Island Better Business Bureau and the Massachusetts Senior Medicare Patrol (MA SMP), an advocacy group assisting seniors with Medicare problems, in resolving this it was felt that mine was not an isolated case and that Steward was looking for opportunities to defraud vulnerable people of their health care benefits while pocketing the insurance discounts. Thus, the referral to you as a legal authority with the power to investigate if any legal wrong doings are taking place and if so proceed to prosecute the offenders. We suspect this could be a serious case of extorsion, insurance fraud, Medicare Fraud and possibility racketeering.
The incident happened last April when my wife, a naturalized USA citizen from Viet Nam, was visiting our daughter in North Andover, MA and she suffered some severe pain in her neck and shoulder. Our daughter took her to the emergency room at Holy Family Hospital in Methuen, MA, a health care facility run by the Steward Healthcare System. After the visit and according to normal procedures we received two billing, one for the hospital charges and the second for the emergency doctor fees. The hospital bill was quickly processed through Medicare and our supplemental insurance and paid. However, the doctors bill was claimed to have been rejected by Medicare as the way it was filed Medicare claimed they did not recognize the individual. Steward then attempted to bill me for the entire $411, that would include the Medicare discount, the Medicare payment and my co-payment. This I immediately protested, and they claimed to have made some token adjustment and resubmitted it to Medicare for which it was again rejected. However, we obtained no notice from Medicare that an attempt to file a claim had been received and rejected. They also attempted by-pass Medicare and go directly to supplemental insurance, Anthem BlueCross/BlueShield. This was done three times and each time the supplemental insurance simply and correctly sent the bill back to Steward billing for Medicare processing before they would make their adjustments and sent me a notice of the claim. Eventually we learned that they were insisting on filing the Medicare claim using her name as it appeared on her Colorado driver’s license instead of as it appeared on her Medicare Card as is the standard practice. They really have no legal need for her driver’s license other than as a convenient means of identification. Eventually, after several months and phone calls and with the assistance of the BBB and the Massachusetts Senior Medicare they relented and processed the Medicare claim using the correct name as it appears on her Medicare card and it appears to be mostly resolved, at least from our perspective.
However, it hard to believe that my case was an isolated incident, but rather part of a systematic attempt to identify vulnerable people whom they thought could be denied their insurance benefits and enticed to make the full payment of quoted services. This would allow the Stewart Healthcare System and its subsidiaries to pocket the normal Medicare or Insurance negotiated discounts. In my case the billed amount was $411, the Medicare allowable was $290, thus if successful Steward Healthcare Systems would profit $121, while I would be the victim of $386 extortion, representing the $411 original billing minus the $25 my actual co-payment once correctly processed. We believe this was a systematic effort at fraud and extorsion because:
1. It is very difficult to accept that a billing office supervisor for a major mega-healthcare organization would not have confronted name permutations and adjustments on a routine basis and know how to adjust for them.
2. This is further exasperated by the basic toying or tinkering approach during phone calls and refusal to allow you to speak to a supervisor, and when the representative from the Senior Medicare Patrol was able to talk to a supervisor the supervisor was adamant that they were doing the correct procedure.
3. This lead to my seriously considering that Stewart had no intention of ever correctly processing my claim and were determined to force me to pay their full billed amount. This can be very distressful as the health care industry can exert tremendous intimidation pressure, with debt collections, credit rating, garnishing wages or pensions, and liens of homes.
4. It also remines me of John Grisham’s book Rainmaker with the healthcare provider (Steward) replacing the insurance company in denying coverage, including having a manual for how to proceed with the fraud once potential victims are identified.
5. It is equally difficult to accept that the billing office supervisor could be a simple overzealous employee working on their own, thus this could only happen with the full implication of the top of the organization and thus we request that any investigation include the CEO, COO, and CFO or corresponding titles as being complicit in the attempted fraud, although their involvement might have some plausible deniability.
6. It is also hard to believe they could treat all case with minor irregularities to this this type of extortion as it would simply overload the billing office. Thus, we think they are using some form of screening process that would include:
a. Legal Immigrants and ethnic minorities who could have some lingering communications difficulties and thus easy to intimidate and more prone to have name permutations as they merge their original culture with the USA culture. That I believe carries a criminal enhancement.
b. Seniors on Medicare whose menial facilities are weakening and are inclined to accept bills as accurate and simply pay them. Again, another potential criminal enhancement.
c. People from out-of-state where the Massachusetts State Attorney is inclined not to get involved as much as a resident.
d. Bills of only a modest size for which it is not worth it to get a lawyer involved.
I hope this is enough to start a full investigation into potential wrongdoing on the part of Stewart. You might look at the extensive complaints filed against Steward with the BBB. They are all related to billing problems and many have simply gone unanswered. If desired I will be happy to share what documentation I have. I don’t think the Commonwealth of Massachusetts nor the USA can afford to tolerate the Mega healthcare providers with their million plus dollar salaries and the political leverage they can apply, to be involved in this type of possible fraudulent management. I do think a detailed forensic audit of their account and perhaps some detailed interviews for lower level billing clerks or former employees will lead to identifying some substantial irregularities that need to be addressed. If you can follow up on this complaint, you might mention to Steward that his type of extortion intimidation management can lead to the high level of frustration among the victims that could ultimately result in the mass workplace shooting that have become too common in the USA. If you can verify that criminal activity is taking place I hope you can prosecute the case to the maximum the law will allow.
Thank you for your assistance with this case.
Colorado State University