HJNO Sep/Oct 2019

Health Insurance Hustle 32 SEP / OCT 2019 I  Healthcare Journal of new orleans   necessary services andwasn’t amedical pro- vider — a “slam dunk case” said the agent on the case. But the testimony served as a cheat sheet for how to defraud the health insurance industry and mostly get away with it. Without irony, the prosecutor, P.J. Meitl, argued thatWilliams had preyed on a health insurance system that relies “on trust, relies on honesty”when it pays claims. He called fraud investigators fromAetna, Cigna and United, who testified that their companies auto-pay millions of claims a year. It’s not cost effective to check them, they said. “Aetna relies on the honesty of the person submitting the claim verifying that it’s true,”testified Kathy Richer, a supervisor in Aetna’s Special Investigations Unit. In a similar manner, Medicare trusts that people who apply for NPI numbers are actu- ally medical providers, Meitl told the jury. Medicare “does not investigate or verify whether an individual is actually a health care provider before issuing anNPI number.” Williams’ attorney, Wes Ball, argued that the case was the sign of a “broken” health care system and blamed insurers for mak- ing a financial decision not to review Wil- liams’ claims before paying them. United failed to protect Southwest’s money, Ball said, and “might be a vendor you might not want to hire.” As for the NPI numbers, anyone could have checkedWilliams’credentials, he said. The jury wasn’t convinced, convicting Williams of four counts of health care fraud. The judge sentenced him to a little more than nine years in federal prison and ordered him to pay $3.9 million in restitution to United, Aetna and Cigna. Insurers promote themselves as guard- ians of health care dollars. United says on its website it wants to “help employers man- age” medical expenses, resulting in “lower costs.” Aetna promises employers “afford- ability.”Cigna promises “increased savings.” But private health insurers allow so much fraud that prosecutors use an idiom to describe the rare person who gets caught: “Pigs get fat, hogs get slaughtered.” “Pigs” can steal millions, if they bill just enough to avoid notice. But if they get greedy and bill too many millions, they “become a data outlier,” said Elliott, the former fraud task force prosecutor. “You get slaughtered.” Williams took years to reach hog status. Part of the problem, experts say, is that health care fraud is oftenmisunderstood as shafting greedy insurers — not the folks pay- ing for health insurance. Ultimately, insurers don’t bear the cost. For their self-funded cli- ents, like Southwest, theymerely process the claims. For their traditionally insured clients, they can recover any losses by increasing deductibles and premiums and decreasing coverage. Williams appears to have duped more than insurers. His twin brother, Dan Wil- liams, recently retired as the assistant special agent in charge of the Dallas field office for criminal investigation for the Internal Rev- enue Service. He spent 27 years ferreting out fraud, and he gets the irony. “You’re not the first person to point that out,” he said. Dan Williams said his brother’s sudden riches from the training business piqued his investigative instincts, but he “trusted” his brother when “he toldme he was authorized to bill insurance companies.” In his letter to ProPublica, Williams did not address the issues in the case or even acknowledge that any of his activities were wrong. Instead, he blamed his former wife. “It grieves me that the consequences of a bitter and hurtful divorce have resulted in the ending of this unprecedented and ben- eficial opportunity to help many people,” he wrote. Lankford and Pratte are proud of their part in ending his scheme, if still baffled that they had to play such a central role in uncovering it. If it hadn’t been for the iPad messages, “I have to believe he would still be billing insurance companies from a Caribbean island,” Pratte said. n “But private health insurers allow so much fraud that prosecutors use an idiom to describe the rare person who gets caught: “Pigs get fat, hogs get slaughtered.”