HJBR Sep/Oct 2019

Health Insurance Hustle 30 SEP / OCT 2019 I  Healthcare Journal of baton rouge   administered by United. He jotted down the name, address, phone number, birthdate and member identification number of the potential clients on a yellow legal pad — all the information the insurer and Southwest would need to investigate the fraud. This is so easy, Pratte recalled thinking as he wrote down the details, all they have to do is cross- reference this. Because Southwest self-funds its benefits, the company was on the hook for the bills, which would eventually total about $2.1 mil- lion according to a source familiar with the case. It paid United to administer the com- pany’s plan and ensure the claims it cov- ered were legitimate. Pratte said he called the airline in the fall of 2015 and spoke to someone in the human resources depart- ment who said they would pass the infor- mation to the right people. “That was the last I heard,” he said. Southwest declined to comment for this story. It still pays United to administer its benefits. Pratte started calling United in the fall of 2014 and spoke to a fraud investigator who took the information with interest, he said. But within a couple of weeks he was told she moved to a different position. Pratte contin- ued calling United over the following two years, making about a dozen calls in total, he said. “He is not a doctor,”Pratte toldwhoever picked up the phone. “So, I don’t see how he can be filing claims.” In early 2015, Lankford emailed additional information to the investigator. The inves- tigator wrote back, thanking Lankford and saying she forwarded the details to the peo- ple who research licenses. “They will inves- tigate further,” she said in the email. Meanwhile, the text messages showed Williams continuing to sign up — and bill for — United members. Frustrated, Pratte made one final call to United in 2016, but he was told the case was closed. United said he’d have to call the Texas Department of Insurance for any additional details. Pratte had already filed a complaint with the regulator but reached out again.The department told him that because he hadn’t personally been defrauded, it would not be able to act on his complaint. To Pratte, it appeared he had struck out withAetna, United, Southwest and the Texas Department of Insurance. “I was trying to get as many people as possible to look into it as I could,”Pratte said recently. “I don’t know if that tells me they are incompetent. Or they don’t care. Or they’re too busy.” A case summary, prepared by the Texas Department of Insurance, shows it first learned of the Williams case in January 2015 but lacked staff to investigate.Aspokes- man said the regulator later received Pratte’s complaint but didn’t pursue it after learn- ing that United had already investigated and closed its case. Meanwhile, some Get Fit With Dave cli- ents had begun noticing odd claims on their insurance statements. Nanette Bishop had heard aboutWilliams when a fellow Southwest flight attendant handed her the trainer’s business card and said, “You’ve got to meet Dr. Dave.” (Bishop said the Southwest legal department advised her not to speak with ProPublica. Details about her interaction with Williams come from court records.) Bishop said she started strong with the workouts but “fizzled”quickly. Her daughter, who was also on her plan and signed up for workouts, only did a couple sessions. Bishop said she had a hard time staying consistent because she was traveling a lot — for much of October 2014 she was in Germany. Later, she noticed in her insurance records that Williams had been paid for dozens of ses- sions over many months, even during the time she’d been abroad. Bishop textedWilliams in January 2015 to tell him he needed to refund all the money. “I never worked out four [times] a week and [my daughter] quit the first week of September,” she wrote. Bishop also called United and SouthwestAirlines to report the overbilling. About a month later, Williams received a letter from a subsidiary of United ordering a review Bishop’s medical records. Another client textedWilliams with con- cerns that her United insurance plan had been billed for 18 workouts in December 2015. That couldn’t be accurate, the woman wrote. “I had to take December off due to my work schedule and family in town,” she wrote. “I understand that people need to be paid but this seems excessive.” While Pratte, Lankford and some of Wil- liams’clients repeatedly flagged bogus bills, the mammoth health insurers reacted with sloth-like urgency to the warnings. Their correspondence shows an almost palpable disinterest in taking decisive action — even while acknowledgingWilliams was fraudu- lently billing them. Cigna appears to have been the quick- est to intervene. In January 2015, Cigna sent Williams a letter, noting that he wasn’t a licensed medical provider and had mis- represented the services he provided. The insurer said he needed to pay back $175,528 $100,000 “And, court records show, the checks from insurance companies, some over $100,000, kept rolling in.”