Waste, fraud, and abuse? For health insurers, fat profits matter more

insurerscam-300x188What happens when a whistle blower provides detailed information about a burly Texan  — with convictions for felony theft and felony injury of a child  — and a burgeoning scam to rip off health insurers for $25 million? Pretty much nothing. For years.

If that sounds outlandish, investigative reporter Marshall Allen has a doozy of a tale to tell about a crook in suburban Fort Worth, Texas named David Williams. His long-running defrauding of some of the nation’s biggest health insurers matters to us all because, as Allen reported for the Pulitzer Prize-winning investigative site ProPublica:

“There are a host of reasons health care costs are out-of-control and routinely top American’s list of financial worries, from unnecessary treatment and high prices to waste and fraud. Most people assume their insurance companies are tightly controlling their health care dollars. Insurers themselves boast of this on their websites. In 2017, private insurance spending hit $1.2 trillion, according to the federal government, yet no one tracks how much is lost to fraud. Some investigators and health care experts estimate that fraud eats up 10% of all health care spending, and they know schemes abound. Williams’ case highlights an unsettling reality about the nation’s health insurance system: It is surprisingly easy for fraudsters to gain entry, and it is shockingly difficult to convince insurance companies to stop them. Williams’ spree also lays bare the financial incentives that drive the system: Rising health care costs boost insurers’ profits. Policing criminals eats away at them. Ultimately, losses are passed on to their clients through higher premiums and out-of-pocket fees or reduced coverage.”

Allen’s well-told investigation includes some jaw-dropping elements, including how easily Williams obtained an important National Provider Identifier, or NPI number. It requires a quick, simple application. But once granted in the Medicare program, it allows medical caregivers to bill insurers.

As Allen discovered, federal regulators operate with total trust that applicants provide true information. Though there are penalties for giving false data to Uncle Sam, regulators could not find an instance where they had sanctioned an applicant for doing so.

Williams, who fell far from the days when he earned a Ph.D. in kinesiology, got not just one but almost a dozen NPI numbers and used them to build a criminal house of cards, exploiting not only the gullability of regulators but also insurers. He advertised for busy people who wanted personal training at the gym — ordinary exercise regimens that health insurers typically won’t pay for. But he figured that he could use certain medical billing codes, and, with his NPI numbers, he submitted health insurance claims for “treatments,” like complex care for back and nerve pain.

His scam built, as he recruited more busy people for low-cost personal training and other, actual trainers and gyms to join him. He persuaded all of them that his operation Get Fit with Dave was legitimate, and the trainers, almost 1,000 of them at one point, did not question how he paid them — via his false health insurance claims.

He was rolling in the dough, so much so that he gave his children, who were living with his ex, computer equipment as gifts. He made a goof, though, tying the devices into his own accounts, allowing his former wife to see his new “business” and how it worked. She, in turn, worked with her dad, a former business executive.

He had both the savvy and time to try to alert insurers, including Aetna, Cigna, and United, to Williams’ scam. He called Texas insurance regulators. He informed Southwest Airlines, knowing that many of its employees were getting taken in the scam and the company would pay for it in higher premiums for its workplace provided coverage. He sent them all with meticulous details of the fraud, including the dates of claims, the individuals insured, the sums sought and paid.

In brief, they yawned, and did little, Allen found.

Pigs prosper, hogs get slaughtered

He explains why, in colorful Texas farm terms: pigs prosper, while hogs get slaughtered. Meaning? Williams’ fraud, though it ran into the tens of millions, was piggish and for the giant, profit-raking insurers was relatively small. Big corporations might overlook and tolerate a little scamming. He eventually, however, stepped over a mystical and fine line and became hoggish in his criminal claims. His fraud rose to be big enough to capture the FBI’s attention. He got his comeuppance, though was it appropriate: nine years imprisonment and $3.9 million in restitution to three insurers?

But what about us, the businesses and patients who will pay ever-rising premiums due to insurer and regulator laxity in dealing with waste, fraud, and abuse? In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care.

This has become an ordeal due to the skyrocketing cost, uncertainty, and complexity of treatments and prescription medications, too many of which prove to be dangerous drugs. Though partisan politicians seem oblivious to it, the reality is that health insurance remains a key means for Americans to share risk and pray to avoid getting slammed by medical costs, which too often leaves them burdened with unconscionable medical debt and may result in medical bankruptcy.

But getting and keeping health coverage — even with the positive effects of the Affordable Care Act, the expansion of Medicaid, and the usefulness of Medicare — can be challenging for Americans. This is especially true with steadily rising premiums and soaring deductibles, notably in employer-provided insurance (which is the way most of us get covered). Insurers are raking in profits, and the least they could do to help their customers is to be aggressive in rooting out waste, fraud, and abuse that adds unnecessary costs to their offerings.

Indeed, Allen offers clear, common sense ways that the health care system could be improved — and Congress should investigate these and make them happen, if appropriate. It’s ridiculous that Uncle Sam doesn’t investigate applicants before giving them NPI numbers. Why aren’t health insurers also checking claims to ensure they’re paying legitimate medical providers? And why aren’t state and federal regulators working hand-in-glove with insurers to detect and root out criminal scams?

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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