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posted by chromas on Sunday July 21 2019, @10:01AM   Printer-friendly
from the ever-wonder-why-health-care-is-so-expensive dept.

Ever since her 14-year marriage imploded in financial chaos and a protective order, Amy Lankford had kept a wary eye on her ex, David Williams.

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 and mostly stumbling. During their marriage, Lankford had been forced to work overtime as a physical therapist 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 saw next made her heart pound. Somehow the iPad had become linked to her ex-husband's personal Apple device and the messages were for him.

Most of the texts were from people setting up workouts through his personal training 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 necessary, not sessions of dumbbell curls and lunges.

Insurance companies also only pay for care provided by licensed medical providers, 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 physician 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 Williams, 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.

Read the rest at ProPublica.


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  • (Score: 3, Insightful) by HiThere on Sunday July 21 2019, @03:59PM (9 children)

    by HiThere (866) Subscriber Badge on Sunday July 21 2019, @03:59PM (#869648) Journal

    While you've got a bit of a point, it's worth noting that a lot of their "improvements" are the US patent office recognizing things as improvements which are trivially better than what was being done elsewhere. It *is* a benefit, in that it acts as a screening mechanism, because a whole lot of "what was being done elsewhere" is true shit, but it's not the kind of improvement you are thinking it is, and they add a whole bunch of costs.

    Additionally, they *do* have a strong preference for things that are treatments rather than cures, for obvious financial reasons. So they don't fork out the kind of money for "human trials" for things that would cure diseases as they do for things that promise recurring payments. (Just consider the efforts they put into Viagra.)

    So. You're partially right. But a different system is still needed. I would personally prefer that research be separated from marketing totally, but designing a workable system is not something I've convinced myself I could do. (I'm not talking about getting it implemented, just a flow-chart level design at the top level.) Saying "That other system was worse than our system" isn't much of a defense. For one thing, the Russians weren't really interested in broadly based medical care, beyond the basics, so your "proof" isn't a valid argument, but more specifically, there's more than two ways of organizing things. State supported academia, for instance, should not have been allowed to have partial ownership in pharmaceutical companies. Just how that law should have been written is not, however, clear. We do want to encourage state sponsorship of academia for multiple valid reasons.

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  • (Score: 1) by fustakrakich on Sunday July 21 2019, @05:59PM (6 children)

    by fustakrakich (6150) on Sunday July 21 2019, @05:59PM (#869683) Journal

    We have to put the government (taxpayer funding) in competition, not cahoots with the industry.

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    • (Score: 2) by The Mighty Buzzard on Monday July 22 2019, @10:33AM (5 children)

      Only works if one side of the competition doesn't get to use its bottomless pockets to put the others out of business by eating a loss longer than they can. That's got to be dealt with any time the government is allowed to compete in the private sector or there is no more private sector very soon.

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      • (Score: 2, Insightful) by fustakrakich on Monday July 22 2019, @07:22PM (4 children)

        by fustakrakich (6150) on Monday July 22 2019, @07:22PM (#870042) Journal

        It's our pockets, we can use them however we want. That's what voting is about, to determine how our tax dollars are spent. The government is our voice, and wallet. So if we want to compete, we have that right.

        And it won't put honest people out of business, only the scammers will feel the pressure.

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        La politica e i criminali sono la stessa cosa..
        • (Score: 2) by The Mighty Buzzard on Tuesday July 23 2019, @04:45AM (3 children)

          The government is our voice, and wallet.

          In an ideal world, yes. Not in this one though.

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          My rights don't end where your fear begins.
          • (Score: 1) by fustakrakich on Tuesday July 23 2019, @05:00AM (2 children)

            by fustakrakich (6150) on Tuesday July 23 2019, @05:00AM (#870224) Journal

            Yes, in this one, right here, right now.

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            • (Score: 2) by The Mighty Buzzard on Tuesday July 23 2019, @09:55AM (1 child)

              You probably want to seek psychological help. Specifically, have them check you for schizophrenia. That's a pretty severe departure from reality.

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              • (Score: 1) by fustakrakich on Tuesday July 23 2019, @06:22PM

                by fustakrakich (6150) on Tuesday July 23 2019, @06:22PM (#870420) Journal

                The world is a bit bigger than your view through the pinhole.

                Your denials of what is in front of you are the real issue.

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                La politica e i criminali sono la stessa cosa..
  • (Score: 2) by driverless on Monday July 22 2019, @01:43AM (1 child)

    by driverless (4770) on Monday July 22 2019, @01:43AM (#869793)

    While you've got a bit of a point, it's worth noting that a lot of their "improvements" are the US patent office recognizing things as improvements which are trivially better than what was being done elsewhere. It *is* a benefit, in that it acts as a screening mechanism

    It's not a benefit, unless you're referring to a financial benefit for the pharma companies. By continuously applying trivial tweaks to standard medicines, they make sure they never go off patent and become generics, which would affect their bottom line. They're not trivially better "improvements", they're trivially different patentable variations.

    • (Score: 2) by HiThere on Monday July 22 2019, @09:12PM

      by HiThere (866) Subscriber Badge on Monday July 22 2019, @09:12PM (#870079) Journal

      What you're talking about happens, but isn't what I was talking about. Generally the drugs that they tweak for new patents are their own drugs, not someone else's. I was thinking more of things like the way they took tea-tree oil, which had been used as a medicine in India since the Vedas were written, and got it patented in the US.

      There's a reasonable argument that what you were talking about is a larger problem, but it didn't fit as directly into the discussion.

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