HJNO Sep/Oct 2019

Health Insurance Hustle 26 SEP / OCT 2019 I  Healthcare Journal of new orleans   only one in here for spanking their child” — and included a dig at his ex-father-in-law, Pratte: “an evil, evil man. He is the reason for my new accommodations.” Williams told Cosio he needed to raise a quick $30,000 to pay an attorney to get him access to his children. “I will need to get a bunch of clients in a hurry.” To set his plan inmotion,Williams needed what is essentially the key that unlocks access to health care dollars: a National Pro- vider Identifier, or NPI number. The ID number is little known outside the medical community but getting one through the federal government’s Medicare program is a rite of passage for medical professionals and organizations. Without it, they can’t bill insurers for their services. One would think obtaining an NPI, with its stamp of legitimacy, would entail at least some basic vetting. But Williams discov- ered and exploited an astonishing loop- hole: Medicare doesn’t check NPI applica- tions for accuracy — a process that should take mere minutes or, if automated, a milli- second. Instead, as one federal prosecutor later noted in court, Medicare “relies on the honesty of applicants.” Records show Williams first applied for an NPI under his own name as far back as 2008. But it wasn’t until 2014 that Williams began to ramp up his scheme, even though nowhe wasn’t just unlicensed, he was a two- time felon. He got a second NPI under the company name, Kinesiology Specialists.The following year, he picked up another under Mansfield Therapy Associates. In 2016, he obtained at least 11 more, often for entities he created in the areas where he found fit- ness clients: Dallas, Nevada, NorthTexas and more. By 2017, he had 20 NPIs, each allow- ing him a new stream of billings. For every NPI application, Williams also obtained a new employer identification number, which is used for tax purposes. But he never hid who he was, using his real name, address, phone number and email address on the applications. He added the title “Dr.”and listed his credentials as “PhD.” Under medical specialty he often indicated he was a “sports medicine”doctor and pro- vided a license number, even though he wasn’t a physician and didn’t have a medi- cal license. Medicare officials declined to be inter- viewed about Williams. But in a state- ment, they acknowledged that the agency doesn’t verify whether an NPI applicant is amedical provider or has a criminal history. The agency claims it would need “explicit authority” from the Department of Health and Human Services to do so — and cur- rently doesn’t have it. Regulations, and potentially the law, would need to be revised to allow the agency to vet the applications, the statement said. Medicare does verify the credentials of physicians and other medical providers who want to bill the agency for their Medicare patients. To those charged with rooting out fraud- sters, the current regulations seem like an invitation to plunder. “Medicare has tomake sure that the indi- viduals who apply for NPIs are licensed phy- sicians — it’s that simple,”said Elliott, the for- mer prosecutor who ran about 100 health care fraud investigations. Elliott, who now does white-collar crim- inal defense, said he knows of two other cases currently under federal investiga- tion in which non-licensed clinic admin- istrators lied to obtain NPI numbers, then used patients’information to file false claims worth millions. Medicare warns NPI applicants that sub- mitting false information could lead to a $250,000 fine and five years in prison. But sinceMedicare started issuing NPIs in 2006, officials said they could not identify anyone who had been sanctioned. So, for those bent on fraud, the first step is easy; the online approval for an NPI takes just minutes. Williams got out of jail in November 2012 and launched an aggressive expansion with an irresistible pitch: Time to get those private personal training sessions you thought you couldn’t afford! “Now accepting most health insur- ance plans,” his Get Fit With Dave website announced. He added a drop-downmenu to his site, allowing potential clients to select their health insurance provider: Aetna. Blue Cross Blue Shield. United. He began building a team, soliciting trainers from the strength and condition- ing department at Texas Christian University. He met with new recruits at local fast food joints or coffee shops to set themup. To the “One would think obtaining an NPI, with its stamp of legitimacy, would entail at least some basic vetting.” NPI Number