Stories
Slash Boxes
Comments

SoylentNews is people

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.


Original Submission

 
This discussion has been archived. No new comments can be posted.
Display Options Threshold/Breakthrough Mark All as Read Mark All as Unread
The Fine Print: The following comments are owned by whoever posted them. We are not responsible for them in any way.
  • (Score: 2, Insightful) by bradley13 on Sunday July 21 2019, @05:25PM (2 children)

    by bradley13 (3053) on Sunday July 21 2019, @05:25PM (#869674) Homepage Journal

    I've read about this more than one. Yes, I know what it is, but...seriously? I have an Internet friend who went to an "in network" hospital, only all of the actual doctors in that hospital were "out of network". WTF?

    Obamacare seems to have destroyed the American healthcare system. Y'all either need to go single payer (and put all of the insurance companies completely out of business), or else you need to go back to something resembling a free-market system. Either of those can work, each has it's advantages and disadvantages. However, at the moment, the US seems to have the absolute worst of both worlds.

    --
    Everyone is somebody else's weirdo.
    Starting Score:    1  point
    Moderation   0  
       Flamebait=1, Insightful=1, Total=2
    Extra 'Insightful' Modifier   0  
    Karma-Bonus Modifier   +1  

    Total Score:   2  
  • (Score: 3, Informative) by Runaway1956 on Sunday July 21 2019, @06:09PM

    by Runaway1956 (2926) Subscriber Badge on Sunday July 21 2019, @06:09PM (#869691) Journal

    Obamacare didn't create those bullshit networks. I think Obamacare may have encouraged the networks, thus making them worse, but Obama didn't create them. I was hearing about in-network and out-of-network way back, maybe while Clinton was still in office. Definitely before Obama came out of the woodwork.

  • (Score: 1, Informative) by Anonymous Coward on Sunday July 21 2019, @07:30PM

    by Anonymous Coward on Sunday July 21 2019, @07:30PM (#869704)

    Unless you've left the US more than 25 years ago, you would have seen the network distinction.

    The fundamental thing for most outsiders to realize about the American system is that, outside of surgical and long term care, it is less of an insurance plan, but an (expensive) discount plan. That means, if you pay $100 per month to a company, they will try to negotiate a price per service, divided between that company and the customer, with local health care providers. That becomes the "network". So if you need a blood test and go to a network provider, you may get a bill for $30. Happen to go to a non-network provider, and you may get charged $3000 like you foolishly ordered the market price lobster in an expensive restaurant.
    If medically necessary, the company will pay 80% of usual and customary rates, but now you're costing them money and you may have to fight them. Usual and customary cost for a blood test may be determined to be $500, so they may pay $400 (assuming you met your deductible), leaving you holding the bag for the remaining $2600. That is somewhat understandable, why should they pay imaginary prices demanded by some provider?