HJBR Sep/Oct 2019

Health Insurance Hustle 32 SEP / OCT 2019 I  Healthcare Journal of baton rouge   everything he could not to get caught,”Maria Gordon-Shydlo said. She acknowledged getting the complaints fromLankford and Pratte, as well as United members, but defended the response of the company, saying it had eventually referred Williams to law enforcement. The insurer is continuing “to improve our processes and enhance our systems so we can catch these schemes on the front- end,” she said, “before a claim is paid and to recoup dollars that were paid as a result of provider misconduct.” In all, United paid Williams more than $3.2 million — most of it after the insurer had caught him in the act. But in reality, the losses weren’t all United’s. Most of the fraud was funded by its client, Southwest. Many health care experts and fraud inves- tigators said they weren’t surprised to hear that insurers were slow to stop even such an outlandish case of fraud. “It’s just not worth it to them,”said Dr. Eric Bricker, an internist who spent years running a company that advised employers who self- funded their insurance. For insurance behemoths pulling in bil- lions, or hundreds of billions, in revenue, fraud that sucks away mere millions is not even a rounding error, he said. And perhaps counterintuitively, insurance companies are loath to offend physicians and hospitals in their all-important net- works — even those accused of wrongdoing, many experts have said. They attract new clients by providing access to their networks. This ambivalence toward fraud, Bricker and others said, is no secret. Scammers like Williams are “emblematic of gazillions of people doing variants of the same thing,” Bricker said. Insurers embolden them by using a catch-and-release approach to fraud, in which the insurers identify crimi- nals, then let them go. Joe Christensen has pursued fraud for both government and commercial insur- ers, serving as a director in Aetna’s Special Investigations Unit, a teamof more than 100 people ferreting out fraud, from2013 to 2018 and as the director of Utah’s insurance fraud division for 13 years. Fraud in government programs, likeMedicare andMedicaid, gets more publicity, he said, and has dedicated arms of agencies pursuing fraudsters. But the losses may be even greater in the com- mercial market because the dollar levels are higher, he said. Some commercial insurers take a pas- sive approach, Christensen said, in part because it’s expensive to press a fraud case. AtAetna, he said, investigators would iden- tify cases of apparent fraud, but it was up to the executives and legal team to decide how to handle them. Taking fraudsters to civil or criminal court requires resources, so the company often settled for trying to get repaid through settlements or blocking a suspect provider from billing, he said. Christensen said while he was at Aetna, investigators almost never sought to part- ner with law enforcement agencies to pur- sue criminal cases. Last spring, he became the SIU director for a Southern California- basedMedicaid plan called L.A. Care Health Plan, where he was allowed to take a proac- tive approach. In just about a year, he said, his much smaller team began 37 criminal investigations with law enforcement agen- cies. The cases are in different stages, but so far there have been seven arrests, four search warrants and one conviction. Chris- tensen recently took a job with an insurer in Utah, where his family lives, so he could be closer to them. ProPublica askedAetna howmany crim- inal cases it had pursued in 2017 and 2018. A company official said the question could not be answered because it does not track such cases. In the spring of 2017, more than four years after Williams first began billing insurers, one of them, United, finally brought him to the attention of the FBI’s heath care fraud squad. One May day, agents from the FBI and the newly engaged Texas Department of Insurance knocked on the door of Wil- liams’ sprawling six-bedroom home — a spread he’d boasted to one trainer that he’d purchased with cash. Williams didn’t invite them in. He refused to answer ques- tions, claiming his attorney had dealt with the questionable billings. Undaunted, just days later, Williams used a freshly minted NPI number to send another bill to United. The last known claim he submitted was on June 3, 2017, according to a source familiar with the investigation. That October, Williams’ long run came to an end when he was arrested by the FBI. $175,528 “I just got a $175K bill in the mail,” Williams 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.”