
Health Care Fraud Takedown - doctoroz
https://www.fbi.gov/news/stories/2015/june/health-care-fraud-takedown/health-care-fraud-takedown
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elliottcarlson
Personal story that relates to this:

A few years back, my wife was finishing up classes to become a cardiovascular
technician. Part of the process to become fully certified is kind of a
chicken/egg scenario - to become ARDMS certified, you need to work under a
cardiologist for a year - but most cardiologists don't want to hire someone
that isn't already ARDMS certified. Anyhow - she was pretty frustrated in how
hard it was becoming to get a foot in to the industry when she finally heard
back from one practice. The interview is conducted in an apartment on the 50th
floor of a luxury building in downtown Manhattan - there were a few other
people there just doing work on laptops. She gets the job, but she immediately
felt something was off - but she wasn't sure what.

For the most part she would help in the "office" and do billing and coding
from some other offices this doctor owned. Sometimes she would be sent out to
one of these offices to actually scan people (which is what she actually
enjoyed and wanted to be doing). And sometimes the doctor would take the whole
team of people working in the "office" out to very fancy dinners where no
expense was spared.

A few months (I think it was about 6 months - but could be wrong) in to this
job, my wife needed a day off for her own doctors appointment, and it turned
out to be a good day to take off - the office was raided by a joint task force
of the FBI and Secret Service - they took the main guy in to custody,
confiscated all the laptops, etc. My wife got a call later that afternoon from
one of the other girls telling her what happened. Eventually my wife was asked
to come in to talk with the FBI twice - they had pictures of her outside of
the building smoking - knew what she had eaten at one of the dinners, etc. She
was cleared from any involvement since she really had no clue what was
actually happening.

In the end, the guy was arrested for Medicare and Medicaid fraud - he had
purchased a radiological service from a doctor that was retiring, and assumed
that doctors identity. He was charged with billing out $32 million in services
that were never performed - $20M to Medicaid, $12M to Medicare. It definitely
seems they were on to him for a little while at least - though I can't find
any more details besides the original press regarding his arrest.

Sadly, my wife lost this time and does not feel right putting it on her resume
- so she remained in the chicken and egg scenario and eventually she went back
to school to broaden her applicable skills so she can actually work in the
field - and hopefully, actually get that certification...

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thr0waway8
Highest paid doctors in the world, and it still wasn't enough for them. And in
case you believe their sob stories about Medicare not paying them enough, read
this:
[http://www.slate.com/blogs/moneybox/2013/01/23/chart_us_gove...](http://www.slate.com/blogs/moneybox/2013/01/23/chart_us_government_spends_more_on_health_care_than_the_canadian_government.html)

~~~
sharpests
Only 19 of the 240 individuals were physicians. And most primary care doctors
in canada make more money than I do, and I'm a surgeon.

As for the medicare thing, it's not just that medicare doesn't pay enough,
it's that about half the time in my practice, medicare simply doesn't pay
anything at all.

Finally, if you want to talk about fraud in medicine, the cited problem isn't
the major fraud issue; it's just the most newsworthy (easily quantifiable
money amount) and therefore an easier target for the men in black.

Not sobbing; I make a good living and am quite happy.

~~~
jacquesm
> Only 19 of the 240 individuals were physicians.

Only?

How does that number compare to the %age of physicians in the total population
of medical professionals?

And why does it matter that GPs in Canada earn more than a surgeon in the US?

~~~
jacalata
The Canada thing is probably a rebuttal to the "highest paid doctors in the
world" line in the original comment.

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choochootrain
i wonder how the medicare fraud strike force is currently doing this, and how
we, as technologists can improve the process.

working around HIPAA makes this an particularly hairy problem but from what i
understand it is still possible to create a compliant solution for hospitals,
emr vendors, and insurance companies, and even patients to detect medical
fraud.

i couldn't find much but maybe some work is already being done in this space?

~~~
anigbrowl
Benford's law is surprisingly effective in detecting unnatural patterns in
data; I believe the IRS relies heavily on it. Then, alert eyes at the payment
end, and encuragement to low-level clerical staff to cooperate in implicating
their bosses or be left holding the bag. This works better for white-collar
crime, since the criminal higher-ups are that much less likely to successfully
put out a hit on persons who informed against them, though sometimes not for
lack of trying.

[https://en.wikipedia.org/?title=Benford%27s_law](https://en.wikipedia.org/?title=Benford%27s_law)

~~~
newman314
I wonder this is applied to find bad actors in the financial sector...

~~~
dbarlett
The FDIC has long recommended [1] mandatory vacation blocks as a fraud-
detection tool:

    
    
        It is the FDIC's goal that all banks have a vacation policy which provides
        that active officers and employees be absent from their duties for an
        uninterrupted period of not less than two consecutive weeks. Such a policy
        is considered an important internal safeguard largely because of the fact
        that perpetration of an embezzlement of any substantial size usually
        requires the constant presence of the embezzler in order to manipulate
        records, respond to inquiries from customers or other employees, and
        otherwise prevent detection.
    

The idea has spread in recent years [2].

[1]
[https://www.fdic.gov/news/news/financial/1995/fil9552.html](https://www.fdic.gov/news/news/financial/1995/fil9552.html)

[2] [http://www.marketplace.org/topics/business/easy-
street/credi...](http://www.marketplace.org/topics/business/easy-
street/credit-suisse-makes-life-little-harder-aspiring-rogue-traders)

~~~
dopeboy
Yep - don't know about the rest but my former employer, Morgan Stanley, has a
mandatory vacation policy (MVP) in place. You must take two consecutive weeks
off per year.

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mgkimsal
If someone bills Medicare for something for me, do I not get a record of that,
indicating the transaction?

I'd expect to have received something saying that "provider X was paid for you
to have equipment Y (or counseling session Z). If this does not seem accurate,
please call 1-800-McGruff". I'd think that would alert people about fraud far
more quickly, no?

~~~
hga
Indeed; being disabled, I'm on Medicare rather early for it, and I get
informed of everything that's billed and associated with me for Medicare Part
B, doctor's office etc. sorts of things (haven't had to go to the hospital so
I don't know about the original Part A). I also have deductibles to pay,
including before my Medigap insurance kicks in.

That said, they could be billing fictitious people, or people sick enough the
extra stuff is easy to miss with all the other charges ... and that's very
possibly how many of these fraudulent outfits were found. There are plenty of
us with personalities in the direction of OCD, my 79 year old mother for
instance, who's I'll admit is pretty healthy and was a RN before I was born,
wouldn't miss anything. Last time I was in the ER for a nasty fall I later
called them up to query a charge of $90 for a TDa?P inoculation, and was
satisfied with their explanation that they had to keep plenty of non-expired
medicines on hand for _everything_ , including unexpected events. In their
case, they had been the primary hospital that received the injured from the
9/11 attack on the Pentagon, and closer to home, a _lot_ more people would
have died than the ~160 in the EF-5 tornado that hit my home town and took out
the other hospital, if they hadn't had ample supplies (see
[http://stormdoctor.blogspot.com/2011/06/first-response-
mode-...](http://stormdoctor.blogspot.com/2011/06/first-response-mode-
may-22-2011-joplin.html) for an idea of just how intense that was)

------
rak
I used to work for a CMS contractor that was involved in th is kind of work.
The level of effort put into fraud, abuse, and waste prevention for Medicare
and Medicaid are amazing. There's still a lot of room for improvement, but it
was a memorable experience working in that field.

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remarkEon
It's rather disgusting that these people were fraudulently billing mental
health services, seeing as how there are many _real_ people who actually need
these services. I'm thinking of veterans of the last 14 years of war. And
anyone else who legitimately needs help.

~~~
jrapdx3
Yes it _is_ disgusting, maddening, and in a way, bizarre considering that
Medicare reimbursement for psychiatric services is shamefully inadequate. (No
question, Medicare reimbursement does not come close to covering the costs of
providing mental health care, hence many professionals won't take Medicare
patients.)

That makes it hard to understand such fraudulent claims, yet the FBI statement
documents claims or payments for psychotherapy that wasn't provided. Seems
like a poor way to defraud the government. The only thing I can think of is
billing a large volume of false claims and thinking low-value services like
mental-health care would slip under the radar.

I'm very glad to see a few "scam artists" were caught. They deserve what's
coming to them, but the ongoing occurrence of fraud suggests fundamental
problems remain unaddressed.

~~~
remarkEon
Honestly, it's embarrassing that people who pretend to be professionals would
do something like this. I agree that there needs to be structural changes to
how we address this issue. I'm not read up enough on the structure of the
problem to propose solutions, but I do know that some people who need the help
might get _some_ help, but eventually run into a wall.

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hippich
For a second I thought it is about how hospitals bill tens of thousands
dollars only to settle for 5% of the total with insurance company (if you are
lucky to have one, otherwise you are screwed)

~~~
imaginenore
Which is the real scam, but somehow billing $20 for an aspirin pill is A-okay.

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a8da6b0c91d
I dare you not to notice some patterns with the names:
[http://www.justice.gov/opa/documents-and-resources-
june-2015...](http://www.justice.gov/opa/documents-and-resources-
june-2015-medicare-fraud-strike-force-press-conference)

~~~
DanBC
They sound like fairly normal American names to me.

What am I missing?

~~~
asanagi
Exactly. What's missing?

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iandanforth
My impression is that money lost to fraud is a tiny fraction of money lost to
legal wasteful spending, lawyers fees, and drug company profits.

Is there any reason to believe these law enforcement activities are an
efficient use of time and labor?

~~~
savanaly
The larger portion of the value of criminal determent is the crimes it
actually deters. We would have to calculate the cost of those crimes (tough to
do-- the cost to society is not the same as the amount stolen, after all,
since the money goes in the pockets of the criminals) that would have been
committed if it was well known there was no enforcement.

