HJBR Sep/Oct 2019

Healthcare Journal of baton rouge I  SEP / OCT 2019 31 andwould not be allowed to continue billing. “I just got a $175K bill in the mail,” Wil- liams texted to a friend. “Cigna insurance has been overpaying me for the past 18 months and they want it back. I knew that they were reimbursing at too high of a rate so I can’t really complain.” By then Williams had more than one National Provider Identifier, so he just switched numbers and kept billing Cigna. More than a year later, in May 2016, Cigna sent another letter, saying he now owed $310,309 for inappropriate payments. In total, the company paid him more than $323,000.Williams never gave any of it back. Cigna declined to comment about the Wil- liams case. Aetna wrote Williams in January 2015 to say it had reviewed his claims and found he wasn’t licensed, resulting in an overpayment of $337,933. The letter said there appeared to be “abusive billing” that gave “rise to a reasonable suspicion of fraud.” But the insurer also gave him a month to provide documentation to dispute the assessment. When Williams hadn’t responded in three months, anAetna investigator wrote toWil- liams’attorney, saying, “We are willing to dis- cuss an amicable resolution of this matter,” and gave him two more weeks to respond. That August, anAetna attorney sent Wil- liams’ attorney another letter, noting that Williams had submitted “fraudulent claims” and had continued to submit bills “even after his billing misconduct was identified.” In January 2016 — a year after Aetna first contacted him—Williams agreed to a settle- ment that required him to refund the com- pany $240,000 “without admission of fault or liability by either party.” But that didn’t stop, or even appear to slow, Williams. Not only did he renege on that promise, he picked one of his other NPI numbers and continued to file claims result- ing in another $300,000 in payments from Aetna. In total, Aetna paid Williams more than $608,000. In emails, Ethan Slavin, a company spokesman, didn’t explainwhyAetna settled with Williams instead of pursuing criminal prosecution. He blamed the insurer’s slow response on the lengthy settlement process andWilliams’tactic of billing under different organizations and tax identification num- bers. Williams did repay some of the money before defaulting, Slavin said. United, one of the largest companies in the country, paid out the most to Williams. The insurer brought in $226 billion last year and has a subsidiary, Optum, devoted to dig- ging out fraud, even for other insurers. But that prowess is not reflected in its dealings withWilliams. In September 2015, United wrote to Wil- liams, noting his lack of a license and the resulting wrongful payments, totaling $636,637. But then the insurer added a baf- fling condition: If Williams didn’t respond, United would pay itself back out of his “future payments.” So while demanding repayment because Williams was not a doctor, the company warned it would dock future claims he would be making as a doctor. Williams responded a month later, not- ing that he had a Ph.D. in kinesiology and did rehab, so he met the qualifications of a sports medicine doctor. United responded in November 2015 with the same argument: he wasn’t licensed and thus needed to repay themoney, againwarn- ing that if he didn’t, United would “initiate repayment by offsetting future payments.” Williams took United up on its offer. “Please offset future payments until the requested refund amount is met,” he responded. Then Williams turned to another NPI number, records show, and continued sub- mitting claims to United. In January 2016, Williams agreed to settle with United and repay $630,000 inmonthly installments of $10,000. Inexplicably, the agreement refers toWilliams as “a provider of medical services or products licensed as appropriate under the laws of the state of TX” and notes that the settlement doesn’t terminate his continued participation in United’s programs. In 2016, Williams obtained a new batch of NPI numbers fromMedicare.As usual, he used his real name, address and credentials on the applications. The additional numbers allowed him to continue to make claims to United. In November 2016, United investiga- tors caught Williams again — twice. They sent two letters accusing him of filing 820 claims between May 2016 and August 2016 and demanded repayment. Again, almost inconceivably, the company threatened to cover his debt with “future payments.” In December 2016, United notified Wil- liams he had only repaid $90,000 of the ini- tial $630,000 he owed and was in default. The following month, United told him he had to pay the remaining $540,000 within 20 days or he could face legal action. Wil- liams replied, saying he wanted to renegoti- ate the settlement, but the insurer declined. Late that month, United said its inappropri- ate payments toWilliams had ballooned to more than $2.3 million. A United spokeswoman said it was dif- ficult to stop Williams because he used variations on his name and different orga- nizations to perpetrate the fraud. “He did