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Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

11/11/99

Ms. Judith Berek
Regional Administrator
HCFA
26 Federal Plaza
New York, NY 10278

Dear Ms. Berek:

I am writing to file a formal complaint against Blue Cross Blue Shield of Western New York, Upstate Medicare (a.k.a. "The Blue Bunglers").

Our office has been experiencing an unusually high number of "electronic claim deletions" from Upstate Medicare recently (involving the following batches of claims S81 - 09/24/99; S82 & S83-09/28/99; S85-10/21/99; S86-10/29/99; S87- 11/09/99).

Yesterday, Upstate Medicare called our office to tell us that they "didn't receive" the batch of Medicare claims we sent to them via modem on 11/09/99. These were clean claims, in the proper electronic format and I personally supervised their transmission to Upstate Medicare. There was nothing wrong with these claims.

Our office has experienced this same type of problem with Upstate Medicare "deleting" our claims in the past when we have either been engaged in filing Medicare appeals or filing complaints against Upstate Medicare for transgressions ranging from wrongful denial of claims to gross negligence and failure to follow Medicare's own laws, rules and regulations. It just so happens that we are currently engaged in filing multiple appeals with Upstate Medicare for many of our non-invasive ultrasound claims which Upstate Medicare has wrongfully denied. We note that Upstate Medicare has failed to follow Medicare's own coding guidelines in denying those claims, and they have repeatedly violated Section 7506.4 of the Medicare carrier's manual in failing to request further information prior to denying those claims. It seems very clear that Upstate Medicare engages in this type of activity (deletion of our claims) as a form of HARASSMENT against physicians who exercise their legal right to appeal or who exercise their legal right to complain to HCFA about poor carrier performance or failure of the carrier to follow Medicare laws, rules, regulations and guidelines. I wrote to HCFA Region II Representative, Mr. Preston Lowen, many times about Upstate Medicare's gross misconduct, including the deliberate deletion of our claims in the past. I also recall writing to Mr. Lowen and suggesting to him that Upstate Medicare was providing FALSE INFORMATION to HCFA to cover up their misdeeds. I also recall suggesting to him that the ACER reports Upstate Medicare is required to file with HCFA were fraudulent. With the recent fraud conviction of former executive vice president of BCBSWNY (Upstate Medicare), we see that I was right (Buffalo News article enclosed for your review). He was convicted of filing FALSE STATEMENTS with HCFA and "FALSIFYING PERFORMANCE REPORTS." He also illegally diverted over One MILLION DOLLARS for which he was fined a mere $15,000. The recent fraud conviction of this Upstate Medicare official, however, likely only represents the "tip of the iceberg" in terms of the widespread fraudulent and negligent activity that goes on at Upstate Medicare. I have reason to believe from our own evperience with Upstate Medicare that they turn off their computers during the daytime at strategic high volume times so that they don't have to receive Medicare claims, they sometimes interfere with (scramble) the transmission of claims, they wrongfully delete electronic Medicare claims, and we have evidence that they have illegally tampered with our electronic claims in the past and have changed the assignment indicator from non-assigned to assigned, and they lie to cover-up their wrongdoing. HCFA, of course, routinely ignores complaints like this against the carrier which is why it took so long to convict the Upstate Medicare official of fraud.

Upstate Medicare needs to be fully investigated for its widespread fraudulent and negligent activity. And, it should not be a "self investigation." They lied to HCFA before and they will lie to HCFA again and again to cover-up their fraudulent activity and wrongdoing. This carrier is harassing our office by wrongfully deleting our Medicare claims and I demand that HCFA take immediate action to stop it!

Sincerely,

L.R. Huntoon, M.D., Ph.D.