HJNO Sep/Oct 2019

Health Insurance Hustle 24 SEP / OCT 2019 I  Healthcare Journal of new orleans   Ever since her 14-year marriage imploded in financial chaos and a protective order, Amy Lankford had kept a wary eye on her ex, DavidWilliams. Williams, then 51, with the beefy body of a former wrestler gone slightly to seed, was always working the angles, looking for shortcuts to success andmostly stumbling. During their marriage, Lankford had been forced to work overtime as a physical ther- apist when his personal training business couldn’t pay his share of the bills. So, when Williams gave their three kids iPad Minis for Christmas in 2013, she was immediately suspicious. Where did he get that kind of money? Then one day on her son’s iPad, she noticed numbers next to the green iMessage icon indicating that new text messages were waiting. She clicked. What she sawnext made her heart pound. Somehow the iPad had become linked to her ex-husband’s personalApple device and the messages were for him. Most of the texts were from people set- ting upworkouts through his personal train- ing business, Get Fit With Dave, which he ran out of his home in Mansfield, Texas, a suburb of Fort Worth. But, oddly, they were also providing their birthdates and the group number of their health insurance plans. The people had health benefits administered by industry giants, including Aetna, Cigna and UnitedHealthcare.They were pleased to hear their health plans would now pay for their fitness workouts. Lankford’s mind raced as she scrolled through the messages. It appeared her ex- husband was getting insurance companies to pay for his personal training services. But how could that be possible? Insurance companies pay for care that’s medically nec- essary, not sessions of dumbbell curls and lunges. Insurance companies also only pay for care provided by licensed medical provid- ers, like doctors or nurses. Williams called himself “Dr. Dave” because he had a Ph.D. in kinesiology. But he didn’t have a medical license. He wasn’t qualified to bill insurance companies. But, Lankford could see, he was doing it anyway. As Lankford would learn, “Dr. Dave” had wrongfully obtained, with breathtaking ease, federal identification numbers that allowed him to fraudulently bill insurers as a physi- cian for services to about 1,000 people.Then he battered the system with the bluntest of ploys: submit a deluge of out-of-network claims, confident that insurers would blindly approve a healthy percentage of them.Then, if the insurers did object, he gambled that they had scant appetite for a fight. By the time the authorities stopped Wil- liams, three years had passed since Lankford had discovered the text messages. In total, records show, he ran the scheme for more than four years, fraudulently billing several of the nation’s top insurance companies — United, Aetna and Cigna — for $25 million and reaping about $4 million in cash. In response to inquiries, Williams sent a brief handwritten letter. He didn’t deny billing the insurers and defended his work, calling it an “unprecedented and beneficial opportunity to help many people.” “My objective was to create a system of preventative medicine,” he wrote. Because of his work, “hundreds of patients” got off their prescription medication and avoided surgery. There are a host of reasons health care costs are out-of-control and routinely top American’s list of financial worries, from unnecessary treatment and high prices to waste and fraud. Most people assume their insurance companies are tightly controlling their health care dollars. Insurers themselves boast of this on their websites. In 2017, private insurance spending hit $1.2 trillion, according to the federal gov- ernment, yet no one tracks how much is lost to fraud. Some investigators and health care experts estimate that fraud eats up 10% of all health care spending, and they know schemes abound. Williams’ case highlights an unsettling reality about the nation’s health insurance system: It is surprisingly easy for fraudsters to gain entry, and it is shockingly difficult to convince insurance companies to stop them. Williams’ spree also lays bare the finan- cial incentives that drive the system: Ris- ing health care costs boost insurers’ prof- its. Policing criminals eats away at them. Ultimately, losses are passed on to their “There are a host of reasons health care costs are out-of-control and routinely top American’s list of financial worries, from unnecessary treatment and high prices to waste and fraud.”