HJNO Sep/Oct 2019

Health Insurance Hustle 28 SEP / OCT 2019 I  Healthcare Journal of new orleans   who is interested in signing up as well,” a new client texted toWilliams. “Tell him to show up with his insurance card,”Williams replied. To Pratte, the text messages were a “gold mine.” This is the stuff that will really nail his rear end, he recalled thinking as he read the messages. He couldn’t wait to share his findings with the insurers. Howoften do they get cases wrapped up in a bow? But when he and Lankford began con- tacting insurers, they were soon bewildered. When Pratte told Aetna that he wanted to report a case of fraud, he said the customer service representative asked for his mem- ber number, then told him non-members couldn’t report criminal activity. Lankford, who happened to be covered byAetna, made the complaint, but they say they never heard back. AnAetna spokesman told ProPublica that the insurer could find no record of Pratte’s call but said the company’s fraud hotline takes tips from anyone, even anonymous callers. Lankford sent an email to Cigna’s special investigations unit in January 2015 “regard- ing one of your providers that concerns me.” She provided Williams’ company name, address, cellphone number, Social Secu- rity number and more, and she described his scheme. “He has no medical license or credentials,” she wrote. “He was in prison for felony theft.” A supervisory investigator called to ask for the names of personal trainers, which Lankford provided. But, again, there was silence. Pratte could see many of the clients worked for Southwest and had their bene- fits administered by United. He jotted down the name, address, phone number, birthdate and member identification number of the potential clients on a yellow legal pad — all the information the insurer and Southwest would need to investigate the fraud. This is so easy, Pratte recalled thinking as he wrote down the details, all they have to do is cross- reference this. Because Southwest self-funds its benefits, the company was on the hook for the bills, which would eventually total about $2.1 mil- lion according to a source familiar with the case. It paid United to administer the com- pany’s plan and ensure the claims it cov- ered were legitimate. Pratte said he called the airline in the fall of 2015 and spoke to someone in the human resources depart- ment who said they would pass the infor- mation to the right people. “That was the last I heard,” he said. Southwest declined to comment for this story. It still pays United to administer its benefits. Pratte started calling United in the fall of 2014 and spoke to a fraud investigator who took the information with interest, he said. But within a couple of weeks he was told she moved to a different position. Pratte contin- ued calling United over the following two years, making about a dozen calls in total, he said. “He is not a doctor,”Pratte toldwhoever picked up the phone. “So, I don’t see how he can be filing claims.” In early 2015, Lankford emailed addi- tional information to the investigator. The investigator wrote back, thanking Lank- ford and saying she forwarded the details to the people who research licenses. “They $100,000 “When Pratte told Aetna that he wanted to report a case of fraud, he said the customer service representative asked for his member number, then told him non-members couldn’t report criminal activity. Lankford, who happened to be covered by Aetna, made the complaint, but they say they never heard back.” “And, court records show, the checks from insurance companies, some over $100,000, kept rolling in.”