Health care ripoffs costing taxpayers millions
A fraud investigator for the federal
Brown billed
Federal investigators did the math. If the doctor had seen one patient every 15 minutes for 10 hours every day for six days a week, he still wouldn't have used 17,000 vials.
When they obtained a search warrant and checked the doctor's office, they discovered he had actually only purchased 254 vials of Botox, according to
Brown pleaded guilty to defrauding
No one seems to know how much health care fraud by medical professionals costs
Unlike conventional thieves, doctors and other medical professionals who steal use the click of a mouse instead of a gun or knife.
How does it work?
Doctors may bill for services that were never performed, as in Brown's case. In another case, investigators used a hidden camera to prove that a
Or doctors or hospitals will bill for services that were not needed. In one of the most-watched local cases, the
In April, two lab professionals from
Fraud charges are also a weapon in the law enforcement crackdown on so-called "pill mills" that prescribe addictive painkillers for people who do not need them and who often re-sell them illegally. The
Another type of fraud involves listing a procedure incorrectly in order to get reimbursement from an insurance company. Instead of listing a nose job as plastic surgery, for example, which isn't covered by insurance, a doctor records it as surgery to repair a deviated septum, which is covered.
The fight against health care fraud is a joint effort among private insurance companies and the state and federal government. In
Since
Both the OIG and the
The insurance companies are on the front line, taking in complaints via a hotline, phone calls, or emails, or their own investigations.
Often a complaint starts with the consumer, who gets a notice in the mail explaining what his or her health insurance paid for.
"Somebody calls us and says they got an Explanation of Benefits. 'It says a doctor saw me on this date -- I didn't see the doctor,'" said
One of the most powerful weapons investigators have are whistleblowers, medical staffers who turn in their bosses for fraud. Under federal law, they can receive a portion of any cash settlement against their employer.
For example, a nurse who worked for
Whistleblowers are particularly useful because they can provide insider information as to who gave the orders to perform a particular activity, making it easier for investigators to determine if the problem was a one-time-only incident or something that was done repeatedly and in more than one facility.
"We rely on the goodness and honesty of practitioners out there, who when they come across something will come to us and tell us what they have been asked to do," said
Investigators often look for how closely a doctor was working with a facility such as a pain clinic or home health care service which is billing
"They are being paid as medical director for a home health care company and all they are doing is signing orders for patients they never see and with whom they have no legitimate patient relationship," the OIG's Haines said.
Fraud investigators all emphasize that most doctors and medical professionals are honest.
"The vast majority of providers are trying to do the right thing," said BlueCross BlueShield's Benson. "We're talking about a small minority of players out there who can make everybody look bad."
Investigators know they are not catching all of the fraud.
"I believe we do make an impact, but unfortunately there is enough of it out there that it keeps us extremely busy," said OIG's Haines.
What is baffling to Tidwell is why some medical professionals commit fraud.
"You have a physician making
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