HJBR Sep/Oct 2019

Healthcare Journal of baton rouge I  SEP / OCT 2019 29 trainers, the business appeared legit: They even signed tax forms. Before long, Wil- liams’ network stretched throughout Texas and into Colorado, Idaho and Nevada. One Fort Worth trainer recalled meeting Williams through one of his clients, a South- west Airlines flight attendant. Williams, he said, seemed like a real doctor, and it wasn’t hard to imagine an insurer’s wellness pro- gram covering fitness. Plus, it was good money — about $50 an hour and Williams paid him for multiple clients at once if he did boot camps, said the trainer, who asked that his name not be used so he wouldn’t be tarnished by his association with Wil- liams. Williams, he said, even gave him an iPad, with “Kinesiology Specialists” etched on the back, to submit bills and paid himvia direct deposit. Clients came to Williams through his business cards, his website and word-of- mouth. Williams, records show, quickly verified if their insurance companies would cover his fees — although he didn’t tell clients that those fees would be billed as medical services, not personal training. To ensure the clients paid nothing, he waived their annual deductibles — the portion patients pay each year before insurance kicks in. Authorities said Williams banked on being able to file enough claims to quickly blow through their deductibles so he could get paid. Meredith Glavin, a flight attendant with Southwest, told the authorities she got in touch with Williams after her co-workers said insurance was covering their work- outs. After providing her name, address and insurance information on the Get Fit With Dave website, Williams emailed back with the good news: “Everything checks out with your insur- ance. My services will be covered at no cost to you.” During a follow-up phone call, Glavin said, they discussed her fitness and weight loss goals and thenWilliams connected her with a trainer.The workouts were typical fit- ness exercises, she said, not treatment for a medical condition. But insurance claims showWilliams billed the sessions as highly complex $300 examinations to treat “lum- bago and sciatica,” a condition in which nerve pain radiates from the lower back into the legs. He used his favorite billing code — 99215 — to bill Glavin’s insurer, United, the claims show. The code is supposed to be used less often because it requires a comprehensive examination and sophisticated medical decision-making, warranting higher reim- bursement. In all, Williams used the code to bill United for more than $20.5 million — without apparently triggering any red flags at the insurer. For that code alone, the insur- ance giant rewarded him with $2.5 million in payments. Eventually, Get Fit With Dave expanded to about a dozen trainers and around 1,000 patients, said a source familiar with the case. And, court records show, the checks from insurance companies, some over $100,000, kept rolling in. Williams bought a couple of pick-up trucks, a new Harley Davidson motorcycle and a fancy house. But greed didn’t seemhis onlymotivation. “I made $50K last week,”he wrote in a December 2014 text to a friend. “Seriously it means nothing. It is not about themoney. I have had a lot taken away from me, and maybe I am trying to prove some- thing ... Maybe it is my way of giving the finger to everyone???” Afewmiles away, his former father-in-law watchedWilliams’illegal business blossom with growing outrage. Pratte kept his grand- son’s iPad on his desk, near his computer, and checked it every day.The texts appeared boring, even routine, but Pratte knew they were evidence of ongoing fraud. “I have another flight attendant friend who is interested in signing up as well,” a new client texted toWilliams. “Tell him to show up with his insurance card,”Williams replied. To Pratte, the text messages were a “gold mine.” This is the stuff that will really nail his rear end, he recalled thinking as he read the messages. He couldn’t wait to share his findings with the insurers. Howoften do they get cases wrapped up in a bow? But when he and Lankford began con- tacting insurers, they were soon bewildered. When Pratte told Aetna that he wanted to report a case of fraud, he said the customer service representative asked for his mem- ber number, then told him non-members couldn’t report criminal activity. Lankford, who happened to be covered byAetna, made the complaint, but they say they never heard back. AnAetna spokesman told ProPublica that the insurer could find no record of Pratte’s call but said the company’s fraud hotline takes tips from anyone, even anonymous callers. Lankford sent an email to Cigna’s special investigations unit in January 2015 “regard- ing one of your providers that concerns me.” She provided Williams’ company name, address, cellphone number, Social Secu- rity number and more, and she described his scheme. “He has no medical license or credentials,” she wrote. “He was in prison for felony theft.” A supervisory investigator called to ask for the names of personal trainers, which Lankford provided. But, again, there was silence. Pratte could see many of the clients worked for Southwest and had their benefits