200 people charged in $2.7B health care fraud crackdown
apnews.com
apnews.com
I guess "step 15" from the book was "marry your criminal associates, so you're not forced to testify against each other": https://en.wikipedia.org/wiki/Spousal_privilege?
Step 1 should be "don't buy any incriminating books related to your planned disappearance" followed by the next chapter, "step 2: too late, already".
The FAA administers aviation, an actual necessary and valuable endeavor. The theatrical display you are subjected to in airports is overseen by DHS as justification for their continued existence as a jobs program. It has nothing to do with aviation.
But yes, the FBI would be happy to have fugitives be caught at an airport checkpoint, although I doubt they’d risk relying on DHS to do it.
Or does getting a notification like this require a warrant or similar court approval first?
The whole sequence of events reads like something straight out of a Vince Gilligan show, like Breaking Bad or Better Call Saul.[a]
The only significant difference is that Gilligan's shows take place in New Mexico instead of Arizona.
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[0] https://www.sars.gov.za/businesses-and-employers/small-busin...
It's so kind of them.
Otherwise yes, any trick that ends up in a popular book would probably not be that useful for people actually trying to flee from law enforcement. Or it would be some super vague advice in the tune of "don't leave traces of you being there".
I see what you didn't do there!
> Reiser found David Simon’s, “Homicide: Life on the Killing Streets” and Masterpieces of Murder by Jonathan Goodman
https://www.eastbaytimes.com/2008/03/06/update-hans-reiser-b...
I read all kinds of non fiction things I won’t even list here but I seem to be a perfectly boring member of society. It’s just interesting subject matter
In addition, such evidence is important in establishing bail, as risk of fleeing is of primary concern.
You sensibly mention that this was not brought up until after the warranted search. But why is this title being mentioned now? Is the suggestion that someone who’s been charged with a crime should not attempt to read up on his rights—that doing so is a black mark suggesting flight risk? If the other book, on disappearing, is derogatory in itself, then why bring up this book too?
Witch hunters during the inquisition literally used to do this sort of thing to help condemn people
International flight means entry/exit searches can happen more easily and/or less likely to be deemed unconstitutional. IANAL.
https://www.northcountrypublicradio.org/news/story/48010/202...
He had fake IDs shipped to his home address through USPS.
The federal agencies definitely knew who he was already. The scene in the library is noteworthy but they would have Got Him without it.
That may constitute bigamy in some states.
These days if you can get someone on the phone with access to an AI you can definitely get some pretty decent motions written, just watch for hallucinated citations.
https://www.eastbaytimes.com/2008/03/06/update-hans-reiser-b...
Hans also claimed to have misplaced the passenger seat (it was missing from the car)
After trial he admitted he threw the passenger seat in a dumpster.
Don't know your rights, people, it's proof you're bad!
> The convictions that follow have to come with severe enough consequences to more than offset the the millions they got while hurting patients and stealing from taxpayers.
I wish they land in prison for many years and then have to pay back what they stole and for all the court fees as well.
Cornwell health does it!
Every single fraudster costs future Americans a ton more money than they just stole
> Another case alleges a scheme in Florida to distribute misbranded HIV drugs. Prosecutors say drugs were bought on the black market and resold to unsuspecting pharmacies, which then provided the medications to patients.
> Some patients were given bottles that contained different drugs than the label showed. One patient ended up unconscious for 24 hours after taking what he was led to believe was his HIV medication but was actually an anti-psychotic drug, prosecutors say.
> Our Story coming soon!
also under "Travel":
> Travel coming soon!
haha no kidding!
[1]: https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
Probably cause no one is going to return your car back.
Really can’t make this stuff up
If you were poor and threw your money at sucker-bait, I might not bully you for it, because the price of the item is punishment enough already.
But if you're rich and buying that, I'm definitely bullying you.
To each their own I suppose?
https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
I think I understand art, items created by skilled craftsmen, special materials, uniqueness...This has none of those properties.
Maybe not as lucky as advertised?
I bet $15 on 'nope'
But yeah, otherwise kind of an odd place.
https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
Goddamn.
Go forth and go crazy with the data, my ML homies!
I've since been wondering if bounties for third parties is a way to mitigate regulatory capture.
That's not peanuts!
Total fraud in that case was $900 million, for a only 500 patients, or almost $2M per patient.
Compromised patient, injured due to basic incompetence, A Medicare probably paid a million dollars or more to treat it.
The billed numbers are almost completely made up. The insurance company (Medicare in this case) will only reimburse up to a set amount.
The reimbursement is calculated as min(billed_amount, allowed_amount). If the facility accidentally bills less than the allowed_amount, they get less than they could have. So to make sure they get 100% of the possible payout, they bill extremely high numbers to insurance.
It's a dumb system, but it's something you have to keep in mind whenever someone talks about how much things cost in the US system. With expensive procedures, products, or drugs, virtually nobody ever pays the big number. It's just a placeholder to make sure insurance payouts are not left on the table.
$1798 total
-$388 Medicare paid
-$1324 Service adjustment
$86 Amount you owe.
I don't think dumb is sufficient to explain this. It's pretty easy for me to see how someone leaps from this de facto legal system to outright fraud, because the line between them is pretty thin.
I'm nearly done dealing with an instance of this myself (for someone else). Had a $1k copay that was legit per their "insurance" plan. The hospital also sent a fraudulent bill for another ~$2k rather than doing the work of figuring out how to bill "insurance" for it. Told them we'd pay in full once they presented a complete set of non-fraudulent bills. Half a year later, with me holding the hands of both bureaucracies, they finally were able to get "insurance" to pay that second bill. I told them we were ready to pay the $1k legit copay, and they told me they had taken care of it months ago using some internal charity fund. The system is an utter joke.
The provider has a list of prices called the chargemaster. The insurance (and Medicare) have lists of prices they'll pay. For private insurance, there will often be negotiations to set prices for patients with the insurer getting treatment at the provider, called the network agreement. These fall between the two lists, generally.
If you're out of network, the provider bills their chargemaster, the insurer tries to pay their price depending on the terms of the insurance. In network, the provider bills the negotiated rate and the insurer (probably) pays it.
Now what happens if the patient doesn't have insurance? The provider bills their chargemaster and the patient (rarely) pays it. If they do, confetti. If they don't, the provider graciously takes a percentage off and offers a repayment plan. They collect on a meaningful percentage of these.
The patient pays more if the chargemaster is higher.
That seems so outside the bounds of reality that I'm questioning if it's what happened here. I can't imagine how that would pass any kind of sniff test by Medicare.
Quote from the article: "In less than two years, more than $900 million in bogus claims were submitted to Medicare for grafts that were used on fewer than 500 patients, prosecutors said."
The alternative interpretation of this is that the grafts were _applied_ to 500 patients, but potentially many many more were billed for grafts that they didn't need (and didn't receive). Maybe more feasible?
Why can't scammer just exercise some moderation and they get to keep scamming for a long time. No, they have to just get greedy. Greed always get you caught
This appears to happen over ~5 years or more - so that's $2.7B vs $22.5T or about 0.012% of total spending.
The reason healthcare is broken in the US is not because of fraud.
It's due to the design.
By the way, fraud is inevitable.
We might be able to save about ~1% per year on healthcare if fraud was reduced to more reasonable levels. That's not going to move the needle at all.
That's a common example but that's not actually what happens at all.
The FBI estimates fraud accounts for upwards of 10% of healthcare expenditures.
One of my clients had their business roped into a multi-million dollar medicaid fraud scheme. The FBI eventually handled it but it months and a lot of work to get the feds interested.
If medicare is representative, fraud is 5-10% of total spend.
https://www.aging.senate.gov/press-releases/lawmakers-join-a...
Fraud is inevitable.
Imagine what $2.7B could do for transit or housing or relocating migrants or student loan debt relief or wildland firefighter pay raises or invasive species remediation. Hell, imagine what even 1% of $2.7B could do for independent journalism or the arts.
Seriously, if they'd just been content with a few million and jetted off to the Caribbean it would have never been noticed. All of these medicare fraud things are always in the multi-millions before they get noticed.
These episodes detail several people who pulled off these same scams, including how others tried to turn them in for it and were ignored.
Asking out of genuine intellectual curiosity, not with political or other overtones (even with the highly political character of the news today).
Most of the 'fraud' that doctors complained about where I lived in Italy was old people coming in with mostly imagined complaints because they're lonely and don't have anyone and a doctor visit is free. Which is kind of sad, but... not the same level of problematic.
I don't think that's a relevant analogy at all. In this case, the doctors were the ones perpetuating the fraud. Not the patients, not the insurance company.
Anytime the person paying is not the one receiving service, the appeal of fraud goes up. When the person paying is not paying with their own money the appeal goes up and a TON of incentives argue against finding fraud. At least in govt, there is sometimes a willful blind eye because finding fraud causes a huge headache and you don't benefit or get paid more. In fact, if you are taking an administrative fee to manage the program, reducing expenditures can hurt your own budget.
I have traveled internationally where folks paid cash for services. It was a bit crazy - they would basically hold you hostage until you paid a bill / impound your car etc. BUT you could buy many drugs OTC (no DR visit even required) and the layers of things like approvals, pre-approvals, billing and billing codes etc simply didn't exist.
Private insurers get defrauded just like Medicare does. They just don’t care; it means they can raise premiums.
https://www.propublica.org/article/we-asked-prosecutors-if-h...
The fraud was perpetuated against Medicare, which is the US-run insurance plan for people 65 and older and people with disabilities. Nearly 20% of the population is on Medicare.
Universally letting everyone on to the plan would have actually allowed them to run the fraud on everyone, not just people on Medicare.
Maybe 6 is Medicaid through a managed care plan.
House of Representatives and Senate offices will provide health coverage to Members of Congress and designated staff through the Small Business Health Options Program (SHOP).
https://www.opm.gov/frequently-asked-questions/insure-faq/he...
They do. Private insurers get defrauded all the time just like Medicare does.
https://www.propublica.org/article/we-asked-prosecutors-if-h...
Investigations are a cost-center. Government can staff investigators; private insurers just factor the fraud into next year's premium hike.
> To put that record in context, take a look at the state’s Medicaid program, which covers about 13 million low-income people. During fiscal 2017 and 2018, the program’s fraud unit filed criminal charges against 321 fraudulent medical providers. It garnered 65 civil settlements and judgments and recovered more than $93 million, according to the state attorney general’s office.
> A rigorous search for civil lawsuits filed by private health insurers over fraud in California turned up just one case in 2017 and 2018. Experts said insurers rarely sue over fraud because of the high cost of litigation.
> I tracked down a dozen or so investigators who once worked for insurers, and they all said the same thing: Insurers don’t police fraud as much as they could because it hurts the bottom line.
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The province’s 12 top-billing doctors — who received payments of between $2 million and $7 million in one year — are overcharging the Ontario Health Insurance Plan, documents obtained by the Star suggest.
[stuff deleted]
Among additional “concerns” alleged in the report:
- Three specialists “inappropriately delegated” duties — for which they billed OHIP and which were supposed to perform themselves — to unqualified individuals to undertake.
- Six claimed to have worked between 356 and 364 days of the year.
- Eight recorded notably high volumes of claims and/or patients. One radiologist, who worked 332 days, billed for 100,000 patients, indicating that more than 300 scans were interpreted per day, the report stated.
- Eleven billed OHIP incorrectly.
- An obstetrician/gynecologist billed for seeing male patients.
====
Loss of license for the nurses and doctors.
People died but the money matters more?
Worse yet, in some cases I am required by law to contract this fraud.
The anti kickback statute and false claims act and cures act are all riddled with ambiguity and cases where normal intuitive business practices become criminal. It just stinks to do business with Medicare.
The idea of just letting fraud go without prosecution in this industry is really hard for me to understand... Did you read the part where someone thought they were taking HIV medications, but because someone was profiting off fraud, they instead took anti-psychotic meds and were unconscious for 24 hours? We don't want to investigate that happening, because it might be bad for business? The business which is wildly thriving?
I see medicare fraud nearly every shift…
I hope you report it. I work a medical adjacent job and we get yearly training on how to report medicare fraud, waste, and abuse.
It’s little things all day.
But the typical prosecution is much more straightforward. A DME retailer whose “clients” are really just identify theft victims. A doctor who signed off on a bunch of things without ever meeting the patients. And some of it is going to get people killed. Especially when they do the scam where they buy HIV medicine from people who get it free and they use lighter fluid (!) to remove labels from the bottle and store the medicine in storage lockers and car trunks before some corrupt pharmacy buys it. Then the thief is back on the plane to whatever ex communist country they came from. There needs to be a deterrent because it is immensely profitable.
All that to say - it's alarmingly easy for a charge to get processed in a batch of other charges, and either insurance pays it without question, or the patient pays it unknowingly. During our experience, we learned that this kind of thing is exceedingly common. The power dynamic between patients and healthcare administration severely misaligned, the information imbalance is huge, and the patient is always in a compromised position.
The article doesn't include details on how they tracked down these criminals (I'm curious to know!), but it wouldn't surprise me in the least if this is just the tip of the iceberg.
Another event in Nashville, my wife cut her hand making dinner. We walked to the emergency room. Eventually someone saw us. He asked whether we wanted to try some experimental tree sap glue to close the wound. Sure? It actually wasn't much of a cut and it had stopped bleeding. No mention of a price. While he was squeezing a droplet of liquid out of a tube the attending physician looked over his shoulder. Yep, checks out. It was basically a glance, less than a minute's interaction and no interaction with out. The whole experience, again, when we had essentially no means to pay, cost hundreds of dollars. They guy who glanced over glue man's shoulder tacked on a couple hundred for himself. Coming through the door and signing some papers then waiting hours to be attended to cost us maybe $400.
I've got similar stories from Washington, DC. My son (not the baby with the hearing test) had to deal with the medical system in Vermont. He's dead now but we're still paying the bills. And now we have insurance.
Regular healthcare in the US looks a hell of a lot like a scam. If you have insurance, the scam is less visible, but it's the same system.
Newborn hearing screening is standard, or even mandated, in most states. This wasn't just a grifter they allowed to roam the halls. They were contracted with the person to administer the tests. It's likely it was even required by your state lawmakers:
Here is the page from the TN department of health that says all newborns should be screened before leaving the hospital or before one month of age: https://www.tn.gov/health/information-for-individuals/i/fact...
If your state is like mine, there might be a law that requires this to be offered at the hospital, along with several other newborn screens.
Newborn hearing screening isn't a scam, and the hospital may not have even had a choice about offering it due to the laws.
We had two kids more after the first one. No one offered to test their hearing or required that it be done. The second one is the one who died, but not from hearing-related complications.
So is everyone else that works any kind of job. 'Solely in it for the money' is such a weird complaint, as if you'd do your job for free if you were independently wealthy.
And that was on top of the $24,000 bill that we had received from hospital. So $32,000 for a no-frills (from a medical viewpoint) birth and that was many years ago.
The health insurance paid 100% of both bills, so we ended up not following up.
[0]: https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
To remedy this, I suggest everyone adopt a system where anyone who stole money or did other financial damage through criminal means spends one day in jail for every $300 of damage they caused.
This has several advantages: 1. The rich would no longer be above the law. 2. It would deter financial crimes and vandalism. 3. It would prevent "victim restitution extortion" where middle-class people are extorted to either give up their life savings or go to prison; They are going to jail regardless, so there is less incentive to set them up to get victim restitution.
Man, I would love the job of catching these crooks.
From a comment on HN recently I located and began watching the French spy series, "The Bureau". The series has in no way convinced me that I want to head to dangerous countries and spy on them. But catching white-collar criminals ripping off the system?
How can I help!
https://www.usatoday.com/story/news/health/2024/06/25/baylor...
Medicare expansion > provider-pigs at the trough. The scale of fraud is heartbreaking.
Source: I'm fin. director for a large "non profit" community health clinic.
What is the name of the "wound care company" that Alexandra Gehrke and Jeffrey King owned?
The government is far more likely to sweat the small stuff. They'll happily pay $20k in staffing to prosecute a $1k theft, because it doesn't hit their profits/bonuses at all to do so.
https://www.propublica.org/article/we-asked-prosecutors-if-h...
> Michael Crowley investigated fraud for more than a decade for three companies, including Humana and United. The flood of fraud was so great, he said, that investigators ignored suspect claims worth less than $300. Investigating those, the companies determined, would cost more than what they could recover, he said.
> But those small claims add up. Williams, the personal trainer from Texas, billed insurers in increments of $300 and under for more than four years, and it added up to about $25 million. “If you’re a provider, you’re going to figure out that threshold real quick and stay under it,” Crowley said.
Edit: Ok, found the actual statement[0]. Indeed AP just pulled this quote completely out of context:
> The fourth pillar of our strategy is ensuring that we keep pace with constantly evolving health care fraud schemes. That includes addressing the rise of schemes that exploit telemedicine technology — specifically as it relates to Adderall and other stimulants.
> Utilizing proactive data analytics, we identified misuse of telemedicine as a possible source of an increase in prescriptions for stimulants. Thereafter, we worked with law enforcement officers to identify potential schemes. Our investigation led us to a digital health care company called Done.
> Earlier this month, we charged and arrested the former CEO and the clinical president of Done for their respective roles in a $100 million scheme to defraud taxpayers and provide easy access to Adderall and other stimulants for no legitimate medical purpose.
> Today, we are also announcing that we have charged an additional five defendants for their alleged involvement in that scheme to distribute more than [40 million] medically unnecessary pills.
> One of the defendants, who was among the company's largest prescribers, was indicted for rubber stamping prescriptions without any medical review. As alleged, the defendant also signed prescriptions for patients who were deceased.
> I want to be clear: it does not matter if you are a trafficker in a drug cartel or a corporate executive or medical professional employed by a health care company. If you profit from the unlawful distribution of controlled substances, you will be held accountable.
So, yeah, Garland is talking about adderall prescriptions. Whereas AP sandwiched the quote between discussion of the (unrelated) Arizona woundcare fraud. Frankly this AP article is a really poor summary of the original DOJ statement and if I were dang I'd update the link to go directly to the DOJ.
[0]: https://www.justice.gov/opa/speech/attorney-general-merrick-...