HJNO Sep/Oct 2019

Health Insurance Hustle 30 SEP / OCT 2019 I  Healthcare Journal of new orleans   that promise, he picked one of his other NPI numbers and continued to file claims result- ing in another $300,000 in payments from Aetna. In total, Aetna paid Williams more than $608,000. In emails, Ethan Slavin, a company spokesman, didn’t explainwhyAetna settled with Williams instead of pursuing criminal prosecution. He blamed the insurer’s slow response on the lengthy settlement process andWilliams’tactic of billing under different organizations and tax identification num- bers. Williams did repay some of themoney before defaulting, Slavin said. United, one of the largest companies in the country, paid out the most to Williams. The insurer brought in $226 billion last year and has a subsidiary, Optum, devoted to dig- ging out fraud, even for other insurers. But that prowess is not reflected in its dealings withWilliams. In September 2015, United wrote to Wil- liams, noting his lack of a license and the resulting wrongful payments, totaling $636,637. But then the insurer added a baf- fling 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. Williams responded a month later, not- ing that he had a Ph.D. in kinesiology and did rehab, so he met the qualifications of a sports medicine doctor. United responded in November 2015 with the same argument: he wasn’t licensed and thus needed to repay themoney, againwarn- ing that if he didn’t, United would “initiate repayment by offsetting future payments.” Williams took United up on its offer. “Please offset future payments until the requested refund amount is met,” he responded. Then Williams turned to another NPI number, records show, and continued sub- mitting claims to United. In January 2016, Williams agreed to settle with United and repay $630,000 inmonthly installments of $10,000. Inexplicably, the agreement refers toWilliams as “a provider of medical services or products licensed as appropriate under the laws of the state of TX” and notes that the settlement doesn’t terminate his continued participation in United’s programs. In 2016, Williams obtained a new batch of NPI numbers fromMedicare.As usual, he used his real name, address and credentials on the applications. The additional numbers allowed him to continue to make claims to United. In November 2016, United investiga- tors 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.” In December 2016, United notified Wil- liams he had only repaid $90,000 of the ini- tial $630,000 he owed and was in default. The following month, United told him he had to pay the remaining $540,000 within 20 days or he could face legal action. Wil- liams replied, saying he wanted to renegoti- ate the settlement, but the insurer declined. Late that month, United said its inappropri- ate payments toWilliams had ballooned to more than $2.3 million. A United spokeswoman said it was dif- ficult to stop Williams because he used variations on his name and different orga- nizations to perpetrate the fraud. “He did everything he could not to get caught,”Maria Gordon-Shydlo said. She acknowledged getting the complaints fromLankford and Pratte, as well as United members, but defended the response of the company, saying it had eventually referred Williams to law enforcement. The insurer is continuing “to improve our processes and enhance our systems so we can catch these schemes on the front- end,” she said, “before a claim is paid and to recoup dollars that were paid as a result of provider misconduct.” In all, United paid Williams more than $3.2 million — most of it after the insurer had caught him in the act. But in reality, the losses weren’t all United’s. Most of the fraud was funded by its client, Southwest. Many health care experts and fraud inves- tigators said they weren’t surprised to hear that insurers were slow to stop even such an outlandish case of fraud. “It’s just not worth it to them,”said Dr. Eric Bricker, an internist who spent years run- ning a company that advised employers who $175,528 “I just got a $175K bill in the mail,” Williams texted to a friend. “Cigna insurance has been overpaying me for the past 18 months and they want it back. I knew that they were reimbursing at too high of a rate so I can’t really complain.”