Physicians may fall prey to quack busters - Health Insurance Portability and Accountability Act

Legislation meant to protect consumers from fraud is sending the medical community into a tailspin. Now legal experts predict loopholes in the new law will launch a wave of criminal prosecution against practitioners of alternative medicine.

The bill in question, the Health Insurance Portability and Accountability Act, went into effect in january. Its stated purpose is to reduce billing fraud and allow consumers to transfer coverage from one employer to another. However, provisions within the bill may give those opposed to alternative medicine -- so-called quack busters -- unprecedented power to prosecute practitioners of non-standard medical therapies. "This law is sort of a cleansing program, a vehicle for driving out those who provide alternative care and those who aren't adhering to a strictly allopathic program," warns Jonathan Emord, a Washington, D.C., attorney who specializes in constitutional law.

The language of the law states that "the practice of complementary or alternative medicine or health-care practice itself would not constitute fraud. " Yet any practitioner "who has failed to comply with certain statutory obligations relating to the quality of health care," including presenting an insurance claim for services considered "inappropriate" or "not medically necessary" could be accused of fraud. Monica Miller, a lobbyist for the Foundation for the Advancement of Innovative Medicine (FAIM), a New York-based physicians advocacy group, thinks the terms "fraud" and "medical necessity" are defined too broadly, adding that some states consider any departure from the prevailing standard of treatment -- meaning mainstream medicine -- substandard and therefore fraudulent.

"We're concerned that the relationship between the patient and physician is going to be damaged by this law," Miller says. "We've been encouraging doctors to be advocates for their patients, but now if they try to suggest anything that is not covered by Medicare [or any health-care benefit program] they can be prosecuted for health fraud. A lot of doctors are really tom." In March 1997, FAIM introduced legislation to the New York State Legislature asking for a definition of "medical necessity."

Currently most alternative caregivers dispense treatments and services that could be considered "fraudulent" by governmental authorities under the new law, according to the American Health Practitioners Association, a College Station, Texas-based legal organization. Before passage, such investigations were handled by state medical boards. Now the authority has shifted to the federal government, giving the attorney general's office $5 billion to audit and investigate health-care practitioners alleged to have engaged in health fraud. A portion of any money recouped in fines from a physician will go to the whistle-blower. According to Emord, this creates an enormous economic incentive for patients to report--and the federal government to prosecute--health-care providers.

Who may be at risk? Both doctors and patients, say experts. For example, imagine that a physician sees a cancer patient and believes the patient should increase her intake of fruits and vegetables. Because that treatment may not be "medically necessary," the doctor could -- theoretically -- be fined for recommending dietary changes. "These provisions will destroy solo practice as we know it, limit the availability of alternative medicine and ensure the arrival of a one-size-fits-all regimen for everyone 6S or older," Emord warns.

For more information about the Health Insurance Portability and Accountability Act of 1996, contact the American Health Practitioners Association at (409) 846-8967 or FAIM at (914) 368-9797. be beneficial for both women and children. "There were many R.D.s who weren't comfortable answering any questions about vegetariarism, " Duncan says.

Using the position paper on vegetarianism as a standard, Duncan interviewed nutritionists in three regions of the country, with Vermont representing the East Coast; Nebraska, the Midwest; and Washington, the West Coast. The results showed that registered dietitians in Vermont and Washington were more likely to be informed of the benefits of a meatless diet and to be inclined to approve of vegetarianism as a way of life. And while half of the dietitians in Vermont had followed a vegetarian diet at some time, only 12 percent of their Midwestern counterparts had ever abstained from eating meat. According to Duncan, this finding suggests that increasing the knowledge base of registered dietitians concerning vegetarian diets may lead them to consider meatless diets in a more positive fight. "I hope this study will allow R.D.s to address gaps in their education," she says.