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200 people charged in $2.7B health care fraud crackdown
- twoodfin 2y ago[flagged]
- ceejayoz 2y agoOh, bullshit. Private insurers get defrauded like this, too. https://www.propublica.org/article/we-asked-prosecutors-if-health-insurance-companies-care-about-fraud-they-laughed-at-us https://www.propublica.org/article/we-asked-prosecutors-if-h... > I called up a former federal fraud prosecutor who’d worked with both Medicare and private insurers. He said my calls to the prosecutors exposed alarming differences in the way fraud is enforced in the private and government health plans. The Medicaid fraud units are “staffed and actively engaged,” said Michael Elliott, who ran about 100 fraud investigations when he worked for the Department of Justice in Texas from 2008 to 2015. > Private insurers, he said, simply don’t make fraud enforcement a big enough part of their mission. “At the end of the day, it shows their priorities are elsewhere,” he said. Plus they commit a good amount themselves: https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html https://www.nytimes.com/2022/10/08/upshot/medicare-advantage...
- twoodfin 2y agoA couple of dumb nobodies bilked Medicare for almost a billion dollars before they got caught. Nothing in that Propublica article gets within an order of magnitude. Also, just looking for fraud complaints is missing the way most insurers combat fraud: They have enough systemic protections to deny the claim in the first place.
- ceejayoz 2y agoProPublica has done an extensive series on this; at least a skim is worth it. Even the industry doesn’t claim to be as effective at combating fraud as you do. https://www.propublica.org/article/health-insurers-make-it-easy-for-scammers-to-steal-millions-who-pays-you https://www.propublica.org/article/health-insurers-make-it-e... > While Pratte, Lankford and some of Williams’ 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 acknowledging Williams was fraudulently billing them. > In September 2015, United wrote to Williams, noting his lack of a license and the resulting wrongful payments, totaling $636,637. But then the insurer added a baffling 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. > In November 2016, United investigators 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.” > Fraud in government programs, like Medicare and Medicaid, gets more publicity, he said, and has dedicated arms of agencies pursuing fraudsters. But the losses may be even greater in the commercial market because the dollar levels are higher, he said. > He called fraud investigators from Aetna, Cigna and United, who testified that their companies auto-pay millions of claims a year. It’s not cost effective to check them, they said. “Aetna relies on the honesty of the person submitting the claim verifying that it’s true,” testified Kathy Richer, a supervisor in Aetna’s Special Investigations Unit. Big catches make for splashy headlines, but for every $2B case that makes national headlines there are a whole bunch of these $25M cases they can’t be bothered to notice. Why would you care about fraud if you can just raise premiums to cover it? My insurer just sent me a letter saying they’re applying for a 21% increase in my $3k/month health insurance policy for next year.
- twoodfin 2y agoStill looking for that 9-figure scam run by (apparently) morons. Are you or Propublica making the claim that private insurers pay out the majority of their claims on trust? Generally we hear the opposite, that they’re looking for any excuse to deny.
- ceejayoz 2y ago> Still looking for that 9-figure scam run by (apparently) morons. Again, the health insurers themselves are doing much bigger scams than nine figures. Eleven figures: https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html https://www.nytimes.com/2022/10/08/upshot/medicare-advantage... "Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion." > Are you or Propublica making the claim that private insurers pay out the majority of their claims on trust? That claim is made, under oath, by a "supervisor in Aetna’s Special Investigations Unit". In a case where the insurers were repeatedly willing to be reimbursed from future payments to a provider they knew was unlicensed, no less. Where were the magical "systemic protections" that private insurers have nearly perfected while Medicare supposedly lacks them entirely?
- Sparkyte 2y agoIf only we can be faster to detect health care fraud.
- cs702 2y ago$2.7B in made-up claims, divided by 200 accused individuals, gives us an average of $13.5M per alleged criminal. That's not peanuts!
- kurthr 2y ago"In the Arizona case, prosecutors have accused two owners of wound care companies of accepting more than $330 million in kickbacks as part of a scheme to fraudulently bill Medicare for amniotic wound grafts, which are dressings to help heal wounds." Total fraud in that case was $900 million, for a only 500 patients, or almost $2M per patient.
- Spooky23 2y agoWound care is bullshit when it’s not fraud. My dad was getting billed $12,000 weekly for treatment of bedsores due to neglect when he was inpatient. The procedure took under 15 minutes. Compromised patient, injured due to basic incompetence, A Medicare probably paid a million dollars or more to treat it.
- proee 2y agoThat is insane. Did his insurance cover this? What happens if you refuse to pay such outlandish fees? I'm sorry he had to deal with this.
- llamaimperative 2y agoGP says Medicare paid for it, so the US taxpayer.
- Aurornis 2y ago> Did his insurance cover this? What happens if you refuse to pay such outlandish fees? The billed numbers are almost completely made up. The insurance company (Medicare in this case) will only reimburse up to a set amount. The reimbursement is calculated as min(billed_amount, allowed_amount). If the facility accidentally bills less than the allowed_amount, they get less than they could have. So to make sure they get 100% of the possible payout, they bill extremely high numbers to insurance. It's a dumb system, but it's something you have to keep in mind whenever someone talks about how much things cost in the US system. With expensive procedures, products, or drugs, virtually nobody ever pays the big number. It's just a placeholder to make sure insurance payouts are not left on the table.
- autoexec 2y agoThis is the sort of action we need more of to help combat corruption and restore some basic faith in the medical industry, but it's only a start. The convictions that follow have to come with severe enough consequences to more than offset the the millions they got while hurting patients and stealing from taxpayers. If the people involved get away with a slap on the wrist or fines that are only a fraction of what they made in profit it will only encourage others to do the same thing. Any doctors accepting kickbacks should, at the very least, lose their license and be prevented from practicing medicine again.
- marcod 2y agoThe other good news of the day was that the Sackler family lost much of their future prosecution immunity https://news.ycombinator.com/item?id=40813369 https://news.ycombinator.com/item?id=40813369
- toomuchtodo 2y agoAlways nice when a little bit of hope shines through the darkness.
- rdtsc 2y agoI suspect this is just a the tip of the iceberg. These clowns are just the dumb ones who got caught. I mean they bought books on "how to disappear" and "how to avoid criminal prosecution". I guess the smart ones get away with it regularly. It's sad really. > The convictions that follow have to come with severe enough consequences to more than offset the the millions they got while hurting patients and stealing from taxpayers. I wish they land in prison for many years and then have to pay back what they stole and for all the court fees as well.
- Icathian 2y agoI worked in this space as a statistician. You are completely correct. The environment is so incredibly target rich and resources are so limited that only the biggest and most obviously winnable cases are pursued.
- bozhark 2y agoJail for the execs. Loss of license for the nurses and doctors. People died but the money matters more?
- RecycledEle 2y agoIf people died that would not have died, is this murder?
- ProllyInfamous 2y agoManslaughter?
- deleted 2y ago[deleted]
- rdtsc 2y ago> Authorities allege Gehrke and King, who got married this year, knew charges were coming and had been preparing to flee. At their home, authorities found a book titled “How To Disappear: Erase Your Digital Footprint, Leave False Trails, and Vanish Without a Trace,” according to court papers. In one of their bags packed for their flight, there was a book titled “Criminal Law Handbook: Know Your Rights, Survive The System,” I guess "step 15" from the book was "marry your criminal associates, so you're not forced to testify against each other": https://en.wikipedia.org/wiki/Spousal_privilege https://en.wikipedia.org/wiki/Spousal_privilege? Step 1 should be "don't buy any incriminating books related to your planned disappearance" followed by the next chapter, "step 2: too late, already".
- marcod 2y agoWould you expect that kind of book to make any difference for final sentencing?
- rdtsc 2y agoI can see it making a difference when presented to jury, if it's admitted as evidence. It may not be main evidence but combined altogether with other things they did, it might tilt the balance into the "sentence them closer the maximum term limit" vs the "lower end".
- wbl 2y agoJudges not juries determine sentences in the US. In federal court the Guidelines are applied resembling nothing so much as a Pathfinder grapple roll.
- armada651 2y agoNo, but it will make a difference in determining whether they're a flight risk by the judge. Given the evidence these two will probably await trail in jail rather than at home. Or at the very least they just bought themselves a nice new ankle bracelet.
- treeFall 2y agoHere's the scammer's wedding registry from earlier this year. They look happy https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-2024 https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
- voganmother42 2y agothe schedule not being chronological is baffling to me, is that a common thing?
- data_ders 2y agolol when you click "our story" [1] it says: > Our Story coming soon! also under "Travel": > Travel coming soon! haha no kidding! [1]: https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-2024/our-story https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
- bustling-noose 2y agoValet parking will be provided for no additional charge according to the FAQ. Probably cause no one is going to return your car back.
- marcod 2y agoDolce&Gabbana Casa Leopard Silk & Wool Throw $3,245.00 - Purchased
- montag 2y agoLouis Vuitton Medallion Blanket $1510.00 - Purchased Really can’t make this stuff up
- hdivider 2y agoI wonder: would this level of fraud occur if the US had universal healthcare, or its effective equivalent? Asking out of genuine intellectual curiosity, not with political or other overtones (even with the highly political character of the news today).
- davidw 2y agoThe biggest scam in US health care is the insurance industry. Most of the 'fraud' that doctors complained about where I lived in Italy was old people coming in with mostly imagined complaints because they're lonely and don't have anyone and a doctor visit is free. Which is kind of sad, but... not the same level of problematic.
- Aurornis 2y ago> Most of the 'fraud' that doctors complained about where I lived in Italy was old people coming in with mostly imagined complaints because they're lonely and don't have anyone and a doctor visit is free. Which is kind of sad, but... not the same level of problematic. I don't think that's a relevant analogy at all. In this case, the doctors were the ones perpetuating the fraud. Not the patients, not the insurance company.
- LeonB 2y agoThere would still be some fraud, but since the prices of basic medical care would be considerably lower (as demonstrated everywhere else in the world) the amount of money made from fraud would be considerably smaller thus creating less incentives.
- glzone1 2y agoThis level of fraud is almost non-existent when there is NO insurance and NO universal healthcare. Anytime the person paying is not the one receiving service, the appeal of fraud goes up. When the person paying is not paying with their own money the appeal goes up and a TON of incentives argue against finding fraud. At least in govt, there is sometimes a willful blind eye because finding fraud causes a huge headache and you don't benefit or get paid more. In fact, if you are taking an administrative fee to manage the program, reducing expenditures can hurt your own budget. I have traveled internationally where folks paid cash for services. It was a bit crazy - they would basically hold you hostage until you paid a bill / impound your car etc. BUT you could buy many drugs OTC (no DR visit even required) and the layers of things like approvals, pre-approvals, billing and billing codes etc simply didn't exist.
- readthenotes1 2y ago[flagged]
- devmor 2y agoIf you're interested in how often people get away with this kind of scam, and how they get away with it, I strongly recommend the two episodes on the subject from the popular podcast "Behind The Bastards" titled "Part One: The Fake Doctors Who Gave Everyone Alzheimer's" and "Behind the Bastards (2018) Part Two: The Real Bastard Was Health Insurance Companies All Along" These episodes detail several people who pulled off these same scams, including how others tried to turn them in for it and were ignored.
- johndhi 2y agoNot to be pedantic, but you suggested general statistics up front (how often people get away with it) then delivered anecdotes later: examples from several people.
- devmor 2y agoTo be intentionally pedantic, I suggested listening to the episodes, in which you would receive both. I did not deliver either.
- guynamedloren 2y agoHorrible, disgusting, yet not at all surprising. I don't know what medical billing accountability looks like in this dizzyingly complex system, but as a US citizen and patient of the US healthcare system, it looks barely existent. My family has fought our fair share of bogus healthcare charges. One instance: after my daughter was born at a birthing center (independent of a hospital), my wife experienced postpartum complications and was transferred to a nearby hospital for care. As if that experience wasn't stressful and traumatic enough, many months later we were hit with a surprise charge from the hospital for treatment and care of our newborn baby - the baby that was delivered hours earlier, in a separate location, that never left my arms in the hospital! All that to say - it's alarmingly easy for a charge to get processed in a batch of other charges, and either insurance pays it without question, or the patient pays it unknowingly. During our experience, we learned that this kind of thing is exceedingly common. The power dynamic between patients and healthcare administration severely misaligned, the information imbalance is huge, and the patient is always in a compromised position. The article doesn't include details on how they tracked down these criminals (I'm curious to know!), but it wouldn't surprise me in the least if this is just the tip of the iceberg.
- DFHippie 2y agoWhen our first child was born (a long, traumatic story in itself), after the ordeal was over and we were resting in the hospital, a nice fellow came by and asked whether we wanted to test our baby's hearing. Sure? No mention was made of a price. He put a device in the baby's ears. Hearing was fine. Then we got the bill. Hundreds of dollars, maybe $500, for a moment's effort and no expenditure of resources. We had almost no money at the time and certainly no insurance. This was in Nashville. He was an independent contractor they let wander the halls of the laying in ward accosting unsuspecting new parents. He bought the machine. Now he's got a steady income from this grift. Another event in Nashville, my wife cut her hand making dinner. We walked to the emergency room. Eventually someone saw us. He asked whether we wanted to try some experimental tree sap glue to close the wound. Sure? It actually wasn't much of a cut and it had stopped bleeding. No mention of a price. While he was squeezing a droplet of liquid out of a tube the attending physician looked over his shoulder. Yep, checks out. It was basically a glance, less than a minute's interaction and no interaction with out. The whole experience, again, when we had essentially no means to pay, cost hundreds of dollars. They guy who glanced over glue man's shoulder tacked on a couple hundred for himself. Coming through the door and signing some papers then waiting hours to be attended to cost us maybe $400. I've got similar stories from Washington, DC. My son (not the baby with the hearing test) had to deal with the medical system in Vermont. He's dead now but we're still paying the bills. And now we have insurance. Regular healthcare in the US looks a hell of a lot like a scam. If you have insurance, the scam is less visible, but it's the same system.
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- RecycledEle 2y agoFrom what I see on the news, rich white-collar criminals get fined a small amount of what they stole and are sentenced to much less jail time than their poorer fellows. To remedy this, I suggest everyone adopt a system where anyone who stole money or did other financial damage through criminal means spends one day in jail for every $300 of damage they caused. This has several advantages: 1. The rich would no longer be above the law. 2. It would deter financial crimes and vandalism. 3. It would prevent "victim restitution extortion" where middle-class people are extorted to either give up their life savings or go to prison; They are going to jail regardless, so there is less incentive to set them up to get victim restitution.
- deleted 2y ago[deleted]
- rqtwteye 2y agoThey are ready to move on to become governor and senator: https://en.wikipedia.org/wiki/Rick_Scott https://en.wikipedia.org/wiki/Rick_Scott
- loeg 2y agoWhy is Garland quoted talking about "profit from the unlawful distribution of controlled substances" when the vast majority of the fraud here had nothing to do with controlled substances? The quote is definitely missing context but it seems inappropriate inserted here. Edit: Ok, found the actual statement[0]. Indeed AP just pulled this quote completely out of context: > The fourth pillar of our strategy is ensuring that we keep pace with constantly evolving health care fraud schemes. That includes addressing the rise of schemes that exploit telemedicine technology — specifically as it relates to Adderall and other stimulants. > Utilizing proactive data analytics, we identified misuse of telemedicine as a possible source of an increase in prescriptions for stimulants. Thereafter, we worked with law enforcement officers to identify potential schemes. Our investigation led us to a digital health care company called Done. > Earlier this month, we charged and arrested the former CEO and the clinical president of Done for their respective roles in a $100 million scheme to defraud taxpayers and provide easy access to Adderall and other stimulants for no legitimate medical purpose. > Today, we are also announcing that we have charged an additional five defendants for their alleged involvement in that scheme to distribute more than [40 million] medically unnecessary pills. > One of the defendants, who was among the company's largest prescribers, was indicted for rubber stamping prescriptions without any medical review. As alleged, the defendant also signed prescriptions for patients who were deceased. > I want to be clear: it does not matter if you are a trafficker in a drug cartel or a corporate executive or medical professional employed by a health care company. If you profit from the unlawful distribution of controlled substances, you will be held accountable. So, yeah, Garland is talking about adderall prescriptions. Whereas AP sandwiched the quote between discussion of the (unrelated) Arizona woundcare fraud. Frankly this AP article is a really poor summary of the original DOJ statement and if I were dang I'd update the link to go directly to the DOJ. [0]: https://www.justice.gov/opa/speech/attorney-general-merrick-b-garland-delivers-remarks-national-health-care-fraud-0 https://www.justice.gov/opa/speech/attorney-general-merrick-...
- mavelikara 2y ago> a wound care company What is the name of the "wound care company" that Alexandra Gehrke and Jeffrey King owned?
- hiatus 2y agoApex Mobile Medical LLC, Apex Medical LLC, Viking Medical Consultants LLC, and APX Mobile Medical LLC.
- mavelikara 2y agoThank you!
- grugagag 2y agoAnd here’s their wedding invite [0]. Money made off dying old people had to sustain their vacuous lifestyle [0]: https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-2024 https://www.theknot.com/us/jeff-king-and-lexie-gehrke-feb-20...
- 1024core 2y ago.... and this is why we will never have universal healthcare. Too many people willing to cheat the system, and the government doesn't sweat the small stuff.
- ceejayoz 2y ago> Too many people willing to cheat the system, and the government doesn't sweat the small stuff. The government is far more likely to sweat the small stuff. They'll happily pay $20k in staffing to prosecute a $1k theft, because it doesn't hit their profits/bonuses at all to do so. https://www.propublica.org/article/we-asked-prosecutors-if-health-insurance-companies-care-about-fraud-they-laughed-at-us https://www.propublica.org/article/we-asked-prosecutors-if-h... > Michael Crowley investigated fraud for more than a decade for three companies, including Humana and United. The flood of fraud was so great, he said, that investigators ignored suspect claims worth less than $300. Investigating those, the companies determined, would cost more than what they could recover, he said. > But those small claims add up. Williams, the personal trainer from Texas, billed insurers in increments of $300 and under for more than four years, and it added up to about $25 million. “If you’re a provider, you’re going to figure out that threshold real quick and stay under it,” Crowley said.
- yelling_cat 2y agoMost of the article is about Gehrke and King, but the last fraud case mentioned is absolutely vile: > Another case alleges a scheme in Florida to distribute misbranded HIV drugs. Prosecutors say drugs were bought on the black market and resold to unsuspecting pharmacies, which then provided the medications to patients. > Some patients were given bottles that contained different drugs than the label showed. One patient ended up unconscious for 24 hours after taking what he was led to believe was his HIV medication but was actually an anti-psychotic drug, prosecutors say.
- 1024core 2y agoHere's an idea: the government (HHS) makes available all public expenditure data (suitably anonymized) and if you can reliably identify fraud, you get 20% cut of the money recovered. Go forth and go crazy with the data, my ML homies!
- _uhtu 2y agoUntil someone spams them with garbage, or uses it to deliberately screw with certain people, and the system starts requiring more people to sift through the garbage than it needed without it.
- EnigmaFlare 2y agoIt wouldn't be randoms on the internet submitting data. Submitting false data could be fraud itself and the people doing it could trivially be identified.
- calpal 2y agoRandom people still would submit things, not fraudulently just poorly. People at large tend to do dumb shit trying to help.
- EnigmaFlare 2y agoIt'd be the organizations spending public money submitting their data. So randoms won't have access to submit things.
- specialist 2y agoIIRC, there's a law practice that solely goes after pharmacy prescription management something something. They make good money. I've since been wondering if bounties for third parties is a way to mitigate regulatory capture.
- SoftTalker 2y agoI'm pretty convinced that this is the tip of the iceberg. I think most end of life care is a scam designed to separate the dying and elderly from their wealth and benefits, before they actually die.
- JKCalhoun 2y ago> The owners of the wound care companies, Alexandra Gehrke and Jeffrey King, were arrested this month at the Phoenix airport as they were boarding a flight to London... Man, I would love the job of catching these crooks. From a comment on HN recently I located and began watching the French spy series, "The Bureau". The series has in no way convinced me that I want to head to dangerous countries and spy on them. But catching white-collar criminals ripping off the system? How can I help!
- johndhi 2y agoMy personal opinion is that the extremely high levels of activity in healthcare fraud prosecutions really aren't good for our country. They sound perfectly bipartisan and like no brainers (I haven't read into the details of this one but assume there are plenty of compelling details) - but it's just another 50lbs on the pile of "healthcare is highly complex and hard to do business in." These rules are BRUTALLY hard to comprehend for businesses. The anti kickback statute and false claims act and cures act are all riddled with ambiguity and cases where normal intuitive business practices become criminal. It just stinks to do business with Medicare.
- palijer 2y agoHealthcare business are fine, the Healthcare industry in America is larger than the retail industry and accounts for 17% of the GDP. Americans spend more per capita on Healthcare than any country, and get worse outcomes. No one is scared about doing business in the industry because the profits are enormous. The idea of just letting fraud go without prosecution in this industry is really hard for me to understand... Did you read the part where someone thought they were taking HIV medications, but because someone was profiting off fraud, they instead took anti-psychotic meds and were unconscious for 24 hours? We don't want to investigate that happening, because it might be bad for business? The business which is wildly thriving?
- 650REDHAIR 2y agoThese aren’t people failing to jump through hoops. I see medicare fraud nearly every shift…
- Suppafly 2y ago>I see medicare fraud nearly every shift… I hope you report it. I work a medical adjacent job and we get yearly training on how to report medicare fraud, waste, and abuse.
- 650REDHAIR 2y agoIt’s too hard to prove it’s A) deliberate B) unnecessary. It’s little things all day.
- xtracto 2y agoInsurance is the Major healthcare fraud,and is widely accepted. I pay a monthly fee to a company for a "service" which actually is on the company's interest to avoid providing. Insurance companies would spend $500,000 in lawyers to prevent paying me $500,001 . Worse yet, in some cases I am required by law to contract this fraud.
- black_13 2y ago[dead]
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- anjel 2y agoThe healthcare system is rotten from top to bottom. https://www.usatoday.com/story/news/health/2024/06/25/baylor-college-of-medicine-settlement/74208300007/ https://www.usatoday.com/story/news/health/2024/06/25/baylor... Medicare expansion > provider-pigs at the trough. The scale of fraud is heartbreaking. Source: I'm fin. director for a large "non profit" community health clinic.