Whisleblowing : Corruption in the US healthcare system


Some major health insurance companies in the USA,  also practice upcoding to milk Medicare and Medicaid. In fact, they are sometimes worse than doctors and nursing homes in billing Medicare and Medicaid, or maybe they are both the same, who knows?

They train their coders how to use ICD9 , now ICD10 codes effectively to make it sure that the insurance company can charge more to Medicare.  In fact,  all laboratory results are being examined/assessed/evaluated to charge more, even if the symptomatology is not yet there,  an excuse of  capturing the illness as early as possible,  to prevent future blown up diagnosis.

A Medicare recipient is like a gold mine to them. I know this very well, because my husband just turned 65, and all hell broke loose. The doctors were feasting on him. Good thing, I used to work for one of the biggest health insurance companies,  I can refute all diagnostic tests ordered, in which some are medically unnecessary, and just a tool to enhance “charging Medicare”.

However, this is just a means of corrupting the system, although, they think that it will save money in the long run. How is that so? The CEO’s and coders are paid very well. It is just moving the funds around.

I was a phone triage RN of another  huge insurance company,  sometime before I got married. We try to assess these patients calling us for symptoms and for some medical/nursing advice.

I was a trained RN in the ER so I know this very well, modesty aside. I spent 6 months being trained as an ER/Critical Care RN, all expenses paid by the hospital that we are working for.

The prime objective of triage is to segregate the patients needing emergency, immediate, or just urgent care.

Issue is that, all patients calling thought that their symptoms require immediate care or all are emergency situation, even a small cut or a small cough requires ER visit. True enough, as  a phone triage RN we sifted the real emergencies from the fake ones.

Therefore, it was worthwhile to be trained and to have a formal education about medicine. Being an experienced Adult Nurse practitioner helped me a lot and including those who seek second opinions. I gave second opinions for free when I was still active in my profession. But I have retired in 2015, so, the only person I can provide medical help are my blood relatives and my beloved husband.

For those who have no idea about what a Nurse Practitioner is,  here is my simple answer. We do what general practitioners do in medicine.  In a nutshell, we function like medical doctors/ general practitioners.  We cover each other in doing “on calls”…Again,  google is your friend.


Leave a Reply

Your email address will not be published. Required fields are marked *