Tag: Insurance

 

Mira Mesa dentist sentenced to 6 years in custody for $866K insurance fraud scheme

A Mira Mesa dentist was sentenced Wednesday to six years in custody and ordered her to pay more than $405,000 in restitution for fraudulently billing 10 insurance companies for hundreds of root canals she did not perform, authorities said.

April Rose Ambrosio, 59, pleaded guilty earlier this year to three counts of insurance fraud as part of a four-year scheme in which she billed the insurance companies $866,700, according to prosecutors and the state insurance commissioner.

Authorities said she was paid $405,633 by the insurance companies. San Diego Superior Court Judge Daniel Goldstein ordered Ambrosio to pay back that money.

She was ordered to serve a split sentence, meaning she will spend three years in county jail and three years on mandatory supervision in the community. California law changed in 2011 to allow some non-violent offenders to serve their prison terms in jail — a situation often described in court as “local prison.”

In September 2019, a judge ordered Ambrosio to stop practicing dentistry. State records show that’s when her license, which was issued in 1990, was suspended.

Authorities said Ambrosio falsely claimed to have performed 800 root canals on 100 patients between 2014 and 2018, even though she lacked the specialized training required to perform root canals.

In some instances, the people she claimed to have performed root canals for had never set foot in her office. In another instance, she billed an insurance company $61,700 for 110 root canals, all of which she claimed to perform on a family of four over just a three-month period in 2016.

“Her deception involved billing for work on days her office was closed, or she was noted as being on vacation,” county prosecutors said in a news release. “In some instances, Ambrosio billed for root canals on non-existent or missing teeth, or she double billed for teeth she previously claimed to have performed root canals on.”

San Diego County District Attorney Summer Stephan said the way that Ambrosio “bilked the system” was “astounding.”

“Unfortunately, when insurance companies get ripped off, consumers ultimately pay the price through higher premiums,” Stephan said in a news release.

Ambrosio’s attorney, Kerry Armstrong, said his client “is extremely remorseful” and ready to begin her sentence next week.

“By all accounts, she was a fantastic dentist to her patients,” Armstrong wrote in an email Wednesday night. “And while she possibly will never get to practice dentistry again, she hopes to work in a field where she can help people once she serves her sentence and regains employment again.”

California Department of Insurance personnel investigated Ambrosio for more than two years and worked with the insurance fraud division of the District Attorney’s Office to prosecute the case.

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Dentist who stole $866K through insurance fraud gets 6 years in prison

SAN DIEGO (CNS) – A former Mira Mesa dentist who bilked insurance companies out of hundreds of thousands of dollars by submitting claims for procedures she never performed, including hundreds of supposed root canals, has been sentenced to six years in state prison, the San Diego County District Attorney’s Office announced Wednesday.

April Rose Ambrosio, 59, pleaded guilty to three counts of insurance fraud earlier this year for fraudulently billing insurance companies for $866,700, for which she received more than $400,000 from 10 insurance companies, according to prosecutors.

The DA’s Office said Ambrosio falsely claimed she performed 800 root canals on 100 patients, despite not having specialized training as an endodontist to perform such procedures.

Ambrosio was sentenced earlier this month, and in addition to a six-year prison term, was ordered to pay $405,633 in restitution. Her license to practice dentistry was also suspended last year, a few months after she was charged.

Prosecutors say the fraud occurred between 2014 and 2018.

During that time, Ambrosio billed for work she said occurred on days her office was closed and billed for more than 100 root canals during a three- month period, all of which were supposedly performed for a family of four, according to the DA’s Office. She also billed for root canals on teeth patients didn’t have or double billed for teeth she previously said she performed root canals on, the DA’s Office said.

“The way this defendant bilked the system is astounding,” District Attorney Summer Stephan said. “Unfortunately, when insurance companies get ripped off, consumers ultimately pay the price through higher premiums.”

Ambrosio’s case was investigated over the course of two years by the California Department of Insurance and the San Diego County District Attorney’s Office.

“This medical provider abused the trust placed in her by fraudulently billing for procedures she never performed and was never trained to perform,” California Insurance Commissioner Ricardo Lara said. “Her illegal actions cost California consumers through higher insurance premiums and erodes the trust consumers hold for honest providers in the dentistry field.”

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Mira Mesa dentist gets six years for false claims to insurance companies

SAN DIEGO (CNS) – A former Mira Mesa dentist who bilked insurance companies out of hundreds of thousands of dollars by submitting claims for procedures she never performed, including hundreds of supposed root canals, has been sentenced to six years in state prison, the San Diego County District Attorney’s Office announced today.

April Rose Ambrosio, 59, pleaded guilty to three counts of insurance fraud earlier this year for fraudulently billing insurance companies for $866,700, for which she received more than $400,000 from 10 insurance companies, according to prosecutors.

The DA’s Office said Ambrosio falsely claimed she performed 800 root canals on 100 patients, despite not having specialized training as an endodontist to perform such procedures.

Ambrosio was sentenced earlier this month, and in addition to a six- year prison term, was ordered to pay $405,633 in restitution. Her license to practice dentistry was also suspended last year, a few months after she was charged.

Prosecutors say the fraud occurred between 2014 and 2018. During that time, Ambrosio billed for work she said occurred on days her office was closed and billed for more than 100 root canals during a three- month period, all of which were supposedly performed for a family of four, according to the DA’s Office. She also billed for root canals on teeth patients didn’t have or double billed for teeth she previously said she performed root canals on, the DA’s Office said.

“The way this defendant bilked the system is astounding,” District Attorney Summer Stephan said. “Unfortunately, when insurance companies get ripped off, consumers ultimately pay the price through higher premiums.”

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Mira Mesa Dentist Gets Six Years For Insurance Fraud

SAN DIEGO, CA — A former Mira Mesa dentist who bilked insurance companies out of hundreds of thousands of dollars by submitting claims for procedures she never performed, including hundreds of supposed root canals, has been sentenced to six years in state prison, the San Diego County District Attorney’s Office announced Wednesday.

April Rose Ambrosio, 59, pleaded guilty to three counts of insurance fraud earlier this year for fraudulently billing insurance companies for $866,700, for which she received more than $400,000 from 10 insurance companies, according to prosecutors.

The DA’s Office said Ambrosio falsely claimed she performed 800 root canals on 100 patients, despite not having specialized training as an endodontist to perform such procedures.

Ambrosio was sentenced earlier this month, and in addition to a six- year prison term, was ordered to pay $405,633 in restitution. Her license to practice dentistry was also suspended last year, a few months after she was charged.

Prosecutors say the fraud occurred between 2014 and 2018.

During that time, Ambrosio billed for work she said occurred on days her office was closed and billed for more than 100 root canals during a three- month period, all of which were supposedly performed for a family of four, according to the DA’s Office. She also billed for root canals on teeth patients didn’t have or double billed for teeth she previously said she performed root canals on, the DA’s Office said.

“The way this defendant bilked the system is astounding,” District Attorney Summer Stephan said. “Unfortunately, when insurance companies get ripped off, consumers ultimately pay the price through higher premiums.”

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Upcoming Supreme Court Ruling Could Jeopardize Health Insurance for People with COVID

The death of Supreme Court Justice Ruth Bader Ginsburg—and President Donald Trump’s controversial nomination of Amy Coney Barrett to fill her seat—have ignited concerns over how a court with a six-to-three conservative majority might rule on an upcoming case on the Affordable Care Act (ACA).

The Senate Judiciary Committee is scheduled to vote on Barrett’s confirmation this Thursday. On November 10 the court will hear Texas v. California. That case will decide whether to uphold a lower court’s ruling that the ACA’s individual mandate to purchase health insurance makes the entire act unconstitutional—or to declare that the mandate is “severable” from the rest of it. If the ACA as a whole is struck down, 20 million people in the U.S. would lose their insurance. Even if it is partially struck down, up to 129 million could lose protections for preexisting conditions—including the more than eight million who have had COVID-19. If she is confirmed before the case is heard, Barrett has given no assurances that she will vote to uphold the landmark health care law.

Many legal scholars say the case for nixing the entire ACA is very weak. But even if the court severs the mandate from most of the law—as Justice Brett Kavanaugh and others have hinted—and strikes down only parts of it, that decision could still do significant damage because the ACA is so intricately tied to the health care system, a number of experts say. Invalidating the law would “throw the nation into economic chaos, in addition to people not having health insurance,” says Georges Benjamin, executive director of the American Public Health Association, a professional organization that promotes public health. “The unintended consequences of even a small tinkering of the ACA could have enormous implications.”

In 2012 the Supreme Court ruled in National Federation of Independent Business v. Sebelius that the ACA’s individual mandate was constitutional because the penalty for not being insured could be considered a tax. But in 2017 Congress passed a tax bill that lowered the penalty to $0, beginning in January 2019. As a result, Texas and other states filed a civil suit claiming the mandate was unconstitutional in 2018. A federal judge in Texas ruled that the individual mandate was unconstitutional and nonseverable, making the entire law unconstitutional—but he did not overturn it. The decision was appealed and eventually made it to the Supreme Court, which is now preparing to hear the case.

A range of different outcomes is possible, according to Katie Keith, a part-time research faculty member at the Center on Health Insurance Reforms at Georgetown University and a principal at the consulting firm Keith Policy Solutions. First, the court will have to determine whether the plaintiffs have standing to challenge the mandate. “If the answer is no, the case kind of goes away,” she says. Second, it must decide whether the mandate is constitutional or not. “Reasonable minds could disagree,” she says, but the case also goes away if the mandate is found to be constitutional.

Does Your Health Insurance Cover Alternative Medicine?

It’s still known as alternative medicine, but services like chiropractic care, acupuncture and therapeutic massage are not that alternative anymore. According to the National Center for Complementary and Integrative Health, almost 40% of adults and 12% of children use complementary or alternative medicine, or CAM, to stay healthy and treat chronic or severe conditions.

Many more would likely use some kind of complementary or alternative treatment if it were covered by their insurance company. While many carriers cover a few services under certain circumstances, most CAM treatments are not covered, forcing patients to pay for it out of their own pocket.

Data from a 2016 study led by the NCCIH suggest that Americans are more and more willing to pay those out-of-pocket charges. Between 2002 and 2012, those who saw a chiropractor rose from 7.5% to 8.3%. The numbers were 1.1% to 1.5% for acupuncture and 5% to 6.9% for massage. Interestingly, usage rates stayed the same for those who had at least some insurance covering the care, but they went up among those who lacked coverage.

For those looking to have complementary or alternative treatments covered, here is what you should know.

[Read: 5 Places to Get Health Care That Aren’t a Clinic.]

CAM Coverage Varies

The NCCIH says that Americans spend about $30.2 billion each year out-of-pocket on complementary health products and practices beyond what their insurance covers. This includes:

— $14.7 billion for visits to such practitioners as chiropractors, acupuncturists and massage therapists.

— $12.8 billion on natural products.

— About $2.7 billion on self-care approaches, including homeopathic medicines and self-help materials, such as books or CDs, related to complementary health topics.

The 2016 study found that 60% of the respondents who had chiropractic care had at least some insurance coverage for it in 2012, but those rates were much lower for acupuncture (25%) and massage (15%). Partial insurance coverage was more common than complete coverage. For chiropractic, nearly 40% of respondents had no coverage, 41.4% had partial and 18.7% had complete coverage. For acupuncture, the breakdown was 75%, 16.5% and 8.55%, and for massage, it was 84.7%, 8.35% and 7%.

The NCCIH says the following complementary or alternative treatments are most often covered to some degree:

Chiropractic: 91% of big insurance companies cover prescribed chiropractic care, most limited to between 15 to 25 prescribed visits with a $20 to $30 copay.

Acupuncture: 32% of big insurance firms cover acupuncture, usually limited to about 20 visits annually.

Massage: Roughly 17% of large insurance firms cover massage therapy, typically if physical therapy and medication hasn’t helped.

Homeopathy: Only 11% of major insurers cover homeopathic remedies.

Hypnosis: Insurers that cover hypnosis require physician authorization, and they typically cover only 50% to 70% of costs.

Biofeedback: Only a few insurers cover the mind-body technique biofeedback, and when they do it’s only for a documented condition like migraines or fibromyalgia.

Naturopathy: Insurers are more likely to cover a licensed naturopath, but

How To Save on Health Insurance

With health care costs soaring through the roof, the cost of health insurance premiums are increasing as well. Health insurance is a necessity, however, when you consider the costs of one visit to the emergency room, surgery to set a broken bone, scans, lab and other costs. When your budget is limited, how can you keep the costs of your health insurance premiums down? There are several steps you can take to reduce your health insurance costs and still maintain adequate medical coverage when you need it.

First step is to consider what health insurance options you have. Does your employer offer a group medical benefit? Many employers (and / or labor unions) offer health benefits to full-time employees. Group health insurance is usually the cheapest way to get medical coverage; an employer can negotiate with health insurance companies to get a group health plan at cheaper rates. In addition, many employers will pay part of the premium, reducing your health insurance cost even further. Another consideration is whether your spouse has health coverage available through their employer? If so, compare your health benefits plan to that of your spouse, and decide which health plan is the better buy. It may be possible to have one spouse carry family health insurance coverage and the other drop their health benefits. Many employers have multiple health insurance options, so review these plans as well. Choose the health plan that best meets your needs at the cheapest rate.

If no health insurance coverage is available through your employer, there are other ways to obtain health insurance coverage. Individual and family private health insurance policies are available. Shop and compare benefits and premiums from each health insurance plan. If you and your family are generally healthy, the new Health Savings Account (HSA) may be worth consideration. The HSA is an account that allows you to save tax-free dollars for your medical / health expenses. Similar to an Individual Retirement Account (IRA), you are limited in the amount that you are allowed to contribute each year; However, with the HSA, withdrawals for health expenses are not penalized, and no tax is paid on the withdrawal. When paired with a health insurance policy that has high deductibles and low rates, the HSA may be ideal for you. Save money in the HSA for deductibles and co-pays, and you're set.

For those over 65 or permanently disabled, Medicare is available through the federal government. The original Medicare is an 80/20 plan (they pay 80% of eligible expenses and the insured pays 20%) with an annual deductible and a monthly premium. Supplemental health plans are available to cover this deductible and co-pay. These supplemental health plans are usually private and the insured pays a premium. In addition to the original Medicare plan, there are Medicare HMOs. In these Medicare HMO health plans, the Medicare premium is paid to an HMO to provide benefits to the insured. HMO plans are more restrictive in that patients must get care through …

Replace and Revise Health Insurance

If the Trump administration truly wanted to repeal and replace healthcare with all the right intentions, then their main focus would not only be targeted at the American people. The administration should include and focus their attention on these type of organizations as well: the large pharmaceutical companies, healthcare providers and insurers. This small list does not include attorneys whose legal expertise at hand is suing companies around the clock and another reason why healthcare cost is out of control. These manufacturers, providers, insurers and law firms are some of the main reasons why health insurance is so costly. Did you know there is no cap on the amount of money insurance companies can charge their customers' for the amount of their monthly premiums?

There is much talk about tax credits, the rising cost of insurance, social economic barriers, and the possibility of Medicaid being phased out altogether by the year 2020. These topics raise a concern. Where and how are people going to afford any type of insurance? In particular, how will those earning minimum wage and are not part of group coverage through their employer health plans afford insurance? The above complexities and legal jargon being used today is just another way to cause confusion.

This is not an hard fix and just another way to keep the American people bamboozled and baffled. One thing that had been done right to a certain degree was when insurers use to calculate and follow the underwriting process. Underwriting is a process when insurers would get information from the medical information bureau to review your medical history to determine risk tolerance. Today, this process has been eliminated; Therefore, insurance companies do not know who they are insuring which causes ridiculous premiums. One way to lower premiums again is to simply allow the underwriting process to begin again. No one's premiums should be higher than their monthly mortgage, even if the entire family is insured. Insurers need to have the freedom once again to underwrite people who are in good health and adjust monthly premiums based on consumers risk factors.

The mandates that are in place under the Affordable Care Act guidelines should remain intact and no one should be denied coverage. Everyone should still be able to get coverage regardless of their pre-existing conditions and if people are financially challenged then there should be financial assistance available to help people afford health insurance. More than enough money is being spent on everything else, such as defense spending and infrastructure, and not enough on humanity. Some states have what is known as cost share reduction plans (csr) which limits the amount of money people pay on their deductible and limits the maximum out of pocket cost consumers would pay in medical expenses.

Ohio, California, and Georgia to name a few have such plans. In addition, the state of New York, is an perfect example for caring for their residents who are economically challenged. They have insurance available for people based on their …

Health Insurance Costs and Modern Medicine

It seems that the more insurance one has the higher go the fees. Doctors now earn substantially more than they did proportionally few years ago. While they know that their patients can recover most of the cost for their service they rarely get an argument from them. In Australia we have the Medicare system that covers everything for those without private health.

The previous Prime Minister, Tony Abbot, put this extra burden on people that they must have health insurance. Only the pensioners above 75 years are now covered by bulk billing. That is they are not charged and the government pays for them. Prior to the Abbot changes everyone had this type of benefit but the cost was unsustainable.

Because of that rise in fees the government is now looking for ways to cut it back even further. The increase in population from overseas migrants is putting an extra burden on the system. Some of these people will go to two or three doctors in the same day thinking they will get better quicker. Some are also getting extra drugs and selling them overseas.

Modern medicine is expensive and now the vets are also on a par with the medical profession as far as fees go. The debate that they do much the same amount of study is a logical claim but when one has no insurance against their bills it is rather tough for many to afford it. Pet ownership is suffering as a result.

We can’t go backwards to old systems because it becomes too complicated. Once people earn more it is hard to take it away again. This is yet another dilemma the government is dealing with as there appears to be no way they can force a decrease in the cost of the medical bills covered by their program. The cost of private insurance is also rising beyond what most and now afford.

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Health Insurance Solutions Part II

Time and time again there is a solution to every problem, challenge, obstacle or anything else that may cause us to fret. Ecclesiastes 3: 1-8. The Affordable Care Act never stated insurer had to do away with the underwriting process. Several elements to sell plans were implemented to conform and to be compliant with the law which included: essential health benefits which are all necessary; with the exception of pediatric dental and vision coverage, especially for someone who does not have minor children in their custody.

The other element is the fact that carriers could no longer deny coverage to consumers who has more than enough health related conditions with exorbitant premiums, terms in the insurance world “rated” because of preexisting conditions.

This is the major problem facing the health sector and why insurers are unable to measure their risk with finding reasonable rates for the American people. This is a shot in the dark for insurance companies to play a guessing game of not knowing who has chronic health problems on a regular basis and what the cost would be to accurately provide care at reasonable prices. Actuaries’ calculate insurance with a purpose; to estimate risk. No measuring stick, no wonder why carriers have lost money over the last several years and are ready to bail out.

The government involvement in the insurance industry is to govern, not necessarily to run the insurance business. It is sad that large carriers are allowing the government to dictate and rule out the main premise of insurance. This business is built on risk factors. There is no difference if you wanted to purchase homeowners, auto; or any other type of insurance, there are risks with insuring property. Our physical bodies are a higher risk since we are moving objects on the go all the time, we wear out and break down time to time and have to be repaired and healed.

Why aren’t insurers addressing this fact with lawmakers? What are the chances of a mechanical breakdown with stationary buildings? Physical buildings breakdown due to neglect and lack of maintenance, or if someone physically damaged the property for whatever reason. When was the last time you purchased property and casualty insurance and your risk wasn’t taken into consideration for how much you will be charged in premium dollars? Well, it is no different with health insurance.

There is a solution and a plan that will work. It is not about taxes, neither is it about how many people will lose coverage, cutting back on Medicaid, squeezing the poor, the rich getting richer or the other non sense we hear from politicians. Insurers need to be bold and follow the guidelines of the current law, go back to the underwriting process, deny no one coverage and have affordable premiums based on risk the way it was in time past; prior-Affordable Care Act.

As consumers, it is our responsibility to take care of these earthly bodies and to protect our finances while we are …