The weird world of healthcare fraud

You have to feel for the healthcare fraudsters out there. It's not as easy as it once was to rake in millions of insurance dollars on false claims scams. These days, you really have to work for your money--or at least harness the power of creative thinking. 

Don't get me wrong. There's still plenty of healthcare fraud out there. Ever since the government has put more resources toward uncovering and prosecuting criminals, the schemes have become a little more … unique.

For example, what better way to spice up a stale marriage than concocting a scheme to rob millions from Medicare? Last week, a husband and wife duo was convicted of health fraud for a scheme in which they set up a sham clinic in Tampa, employed unlicensed medical professionals, and then had recruiters drive beneficiaries to the clinic so they could bill for services that were never rendered, according to the Department of Justice (DOJ). Then the happy couple convinced patients to sign up for Universal Medicare Part C and D so they could bill the program for expensive HIV drugs that were never needed. In a marriage, it's all about making that extra effort.

Maybe they got the idea from two other couples in South Florida, who settled false claims charges a month earlier. Alan and Lynn Buhler, M.D., and Craig and Cynthia Prokos, M.D., were roped into an innovative scheme involving A Plus Home Care Inc., the DOJ said. In an effort to improve referrals, A Plus hired the wives of the two doctors as marketers, a position that served entirely as a means of siphoning money to the physicians in exchange for Medicare referrals. Their salaries served as kickback payments to the doctors as part of scheme that cost Medicare more than $1 million.

If you're a college sports fan, maybe you'll find these next two schemes interesting. In March, federal investigators released details of an investigation of Eric Leak, a former wide receiver at North Carolina State University. Leak owned Nature's Reflection, a mental health clinic that apparently served as a funding source for his other business, Hot Shot Sports Management. Between 2012 and 2014, Nature's Reflections billed Medicaid $8.7 million in false claims. In one instance, a patient who was linked to 100 visits said she had never even heard of the company.

A federal warrant includes an exchange with a Nature's Reflection employee that brought concerns to Leak regarding a claim for services that weren't actually rendered.

"It doesn't matter if you actually see them--you're not actually helping them," Leak replied, according to the warrant.

If that's not bad enough, Leak apparently used the money to fund his sports management company, which bought Porsches and other luxury cars for NC State athletes. How thoughtful!

Another scam in New Orleans implicated the mother of former Louisiana State University football star and current safety for the Arizona Cardinals, Tyrann Mathieu. Mathieu's mother Sheila, a registered nurse, played a role in a 20-person, $30 million home health scam in which she allegedly falsified home health assessments in order to inflate Medicare reimbursement rates, FierceHealthPayer: AntiFraud previously reported.

In some cases, it's better to work by yourself, like the New Jersey doctor who billed for face-to-face patient visits when he was actually writing prescriptions, authorizing refills, or "performing other tasks," as the FBI put it. (Feel free to let your imagination run wild on that one. Perhaps he was catching up on episodes of Breaking Bad--in which case, who can blame him?) Or there's the Oklahoma doctor who apparently altered the space-time continuum in an Interstellar-esque billing scheme in which he claimed to have worked more than 24 hours in one day, according to the Oklahoman. There truly aren't enough hours in the day.

Prison will do strange things to a person. In the case of one woman, it might lead to billing Medicaid from jail, which is just downright impressive, if you ask me. Or, how about the four Tallahassee residents who recruited homeless patients to bill Medicaid a couple thousand dollars? Although, to be fair, that scheme is so 2013.

Maybe these schemes leave you feeling a bit unsettled, but look at it this way: At least human ingenuity is alive and well. Say what you want about these fraudsters, but they are certainly willing to stand out from the crowd, even if it's at the expense of taxpayers, the homeless or their marital bliss. - Evan (@HealthPayer)

Suggested Articles

The HHS OIG is asking for an additional $23.7 million to support fraud oversight that has benefited from an emphasis on data analytics.

A New York surgeon was sentenced to 13 years in prison for fraud and more physician practice news from around the web.

A federal judge has ruled that the U.S. government’s remaining fraud case against UnitedHealth can move forward.