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Health care fraud: senators call for closing “loopholes” that make it easy

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Following a detailed account of how scam artists can easily gain access to health care cash, six Democratic senators this week sent a letter to federal regulators urging them to “close loopholes” that allow “bad actors” to commit fraud.

The letter came in response to a recent story by ProPublica and Vox that traced the brazen scam of a Texas personal trainer, who despite having no medical credentials was able to submit a blizzard of fake bills with some of the biggest insurance companies in the country and recoup millions. The story revealed not only how David Williams exploited weaknesses at each step, but also that the insurers were extremely slow in responding to his ongoing fraud.

Williams’s con, for which he was later prosecuted, was initially enabled by the Centers for Medicare and Medicaid Services. The federal agency issues and administers National Provider Identifiers, or NPIs, the unique numbers medical providers need to bill insurance plans. ProPublica found that Medicare doesn’t check the credentials of medical providers who apply for NPI numbers, such as whether they have valid licenses, which means scammers can lie to obtain them. Williams obtained at least 20 NPI numbers and used them to bill insurers.

The insurers he scammed — Aetna, Cigna, and UnitedHealthcare — then allowed his fraud to proceed for years, largely unchecked. The companies also failed to verify that Williams was a licensed physician, even as he billed them for complex, and expensive, office visits as an out-of-network provider. Instead, they paid him more than $4 million over four years, despite alerts from his ex-wife and her dad about his scam. Williams was convicted on four counts of health care fraud in 2018 and sentenced to about nine years in federal prison. The insurers declined to comment on his fraud.

Current and former investigators for health insurers and federal prosecutors said the simplicity of Williams’s scam, combined with weak oversight and enforcement, raises questions about what’s being done to combat rampant health care fraud. Experts estimate that fraud consumes about 10 percent of the country’s $3.5 trillion health care tab — although the story found that large swaths of fraud are not being tracked. Those losses are eventually passed on to the public in the form of higher monthly premiums and out-of-pocket costs as well as reduced benefits.

In their letter, the senators asked the leaders of the Department of Health and Human Services and its Medicare division to detail what they’re doing to fix gaps in the system that allow fraud to flourish, including what measures Medicare has taken to strengthen the requirements for obtaining an NPI number. “Commercial health plans and their enrollees depend on the validity of federal provider identification systems in order to ensure that patients’ dollars are well spent,” the senators wrote.

In a separate email, Sen. Catherine Cortez Masto of Nevada, who spearheaded the response, said ProPublica’s reporting “highlighted an area where the government could be stemming fraud but isn’t.”

She and her colleagues, she said, “want to know how CMS is using its authority to safeguard against health care scams like the one David Williams carried out for years.”

And she noted that if the senators “find that the agency can be doing more, then we will look to arm CMS with the tools it needs to protect patients and taxpayers, or hold them accountable for the failure to use tools already at their disposal.”

A spokesperson for Medicare said the agency would not comment on the senators’ letter but would be responding to it. The agency has previously said that federal regulations don’t allow it to verify the licenses of NPI applicants. In their letter, the lawmakers said they would work with the regulators to identify any authority Medicare needs to address the security gaps.

In an email sent to ProPublica after the Williams story was published, Medicare officials quibbled with the story’s description of the NPI as “essentially the key that unlocks access to health care dollars.” A Medicare spokesperson said the phrase overstated the NPI’s significance because the identifier doesn’t guarantee payment or enrollment in a health plan or that the provider is licensed.

But Medicare’s own literature says medical providers and plans “must use NPIs” in their financial transactions. Any claim submitted for payment is required to include a valid NPI.

Medicare also asserted that providers must enroll with a health insurance plan to get paid. That’s true for Medicare, which covers people who are disabled or over age 65. But it’s often not the case with private insurers. The Williams story showed how “out of network” providers — those who are not part of a private insurer’s network — can still get paid.

Joe Christensen, who spent five years as a director in Aetna’s Special Investigations Unit and 13 years as director of Utah’s insurance fraud division, said health plans typically pay out-of-network claims without checking the providers’ credentials. He said that makes the integrity of NPIs essential. “Anybody with an NPI can bill,” Christensen said. Others experts told ProPublica the same thing.

Out-of-network billing is common with private insurance plans. A JAMA Internal Medicine study published this week showed that about 42 percent of privately insured patients at in-network hospitals got out-of-network bills in 2016. If providers’ licenses are not verified when they obtain an NPI, or when they submit an out-of-network bill to a commercial insurer, it creates a massive opportunity for scammers.

The Williams story also detailed the sluggish response of insurers to clear evidence of fraud. Williams’s ex-wife, Amy Lankford, and her father, Jim Pratte, discovered the fraud by happenstance and reported it to regulators and the insurers for years. Even after the insurers had ascertained that Williams was not a doctor, they continued to process his bills and pay him because he used new NPIs.

In their letter, the senators also asked what Medicare could do to hold insurance companies accountable for their response to fraud.

On Tuesday, Pratte said the senators’ letter gave him hope. “It’s totally ridiculous,” he said. “Common sense would say you have to have some kind of credentials verified before an NPI can be issued.”

Verifying NPI applicants’ credentials “would be a simple and significant step in addressing those issues,” Pratte said.

The letter was signed by Sens. Cortez Masto, Sheldon Whitehouse of Rhode Island, Maggie Hassan of New Hampshire, Tammy Duckworth of Illinois, Michael Bennet of Colorado, and Bob Menendez of New Jersey. The senators requested a response, in writing, by September 9.

Have you worked in health insurance or employer-sponsored health benefits? ProPublica is investigating the industry and wants to hear from you. Please complete this brief questionnaire.

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Full E-book The Secrets of Economic Indicators: Hidden Clues to Future Economic Trends and

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https://bookzxy.blogspot.com/?book=0132932075

Paperback. Pub Date :2012-08-03 Pages: 496 Language: English Publisher: FT Press For years. investors. business strategists. and policymakers worldwide have turned to one book to help them translate the massive flow of economic data into knowledge for intelligent decision-making. The Wall Street Journal called this book … the real deal. saying it miraculously breathes life into economic indicators and statistics. That book is Bernie Baumohl s classic best-seller The Secrets of Economic Indicators. Now. in a brand-new Third Edition. Baumohl has thoroughly updated his classic to reflect the latest US and foreign economic indicators. and brand-new insights into what all of today s leading indicators mean. Baumohl introduces dozens of new. forward-looking economic markers. including those that monitor small business plans. freight traffic shifts. web searches. and even gamblin…

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7 Hidden Messages in “Alice’s Adventures in Wonderland” That Weren’t Meant for Kids

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Lewis Carroll’s tale Alice’s Adventures in Wonderland had an amazing influence on cinema, literature, and even psychology: movies and ballets were based on it, sequels and remakes were written. There is even a psychological disorder named after the main character: Alice in Wonderland Syndrome (AWS). This seemingly innocent children’s story was the subject of heated discussions by scientists of the 20th century and even Freud talked about it. The point of the discussions was simple: was the tale written for children or for adults?

Bright Side has read the book “Alice’s Adventures in Wonderland Decoded” and tried to figure out which parts of the story can only be understood by adults.

1. Alice’s shrinking and growing is a sign of puberty.

When Alice ate a cake or drank a certain mixture, Alice would shrink or grow, and she was scared that she would disappear completely. While there were no actual reasons for the changes in her body in the text, scientists have 3 versions of what could have been the hidden meaning behind that episode:

  • Alice’s body changes in a similar way to how it would change as a teenager during puberty. Many people think that Carroll showed the puberty of the character. But why this idea may also be wrong is because Alice is only 7 years old and it is too young to be a teenager.
  • Astronomers link the character with the expanding Universe. According to one of the theories, the amount of matter in the Universe is constantly decreasing which will ultimately lead to its disappearance. Obviously, this is why the character was worried about shrinking so much that she would vanish.
  • Other people see an indication of hallucinogenic substances, which make people completely disoriented, just like Alice.

2. The pig the character has is an English King.

It is believed that the tale is an allusion to the War of the Roses that took place in England in the 15th century. This time period was full of scheming, betrayal, and there were a lot of chopped heads — just like in the tale.

Assuming the guess is correct, then baby that turned into the pig is a member of the White Rose. And more specifically, it was Richard III who had a sigil with a white boar. Shakespeare even wrote a play about it where he presented Richard in a very bad light.

3. The smell of pepper in the house of the Duchess hides the smell of bad food.

The tale casually mentions that the house of the Duchess smells a lot like pepper because the scullery was adding pepper to the soup. But it may have been a hint at the problem that the food at the time was peppered a lot, to kill the smell of rotten ingredients.

4. Alice is Eve, who becomes a sinner.

The adventures of Alice starts in a quiet garden. It was an idyllic place, green and quiet, and that’s why it reminds many people the Garden of Eden. But Alice doesn’t take an apple, she goes down the rabbit hole and goes into a world that gives rise to incredible changes in her. This theory seems to be pretty logical: children are innocent but when Alice went into the hole (took the apple), she entered the world of puberty, adult life, and became a sinner.

5. Keys, doors, and caterpillars are Freudian symbols.

When Freudian theories became very popular around the world, the tale of Alice turned out to be full of gynecological symbols. The fans of Freud managed to see the symbols in the doors that were hidden behind the curtains, and keys that open these doors. Of course, they couldn’t have missed Absolem — the giant caterpillar that looks like a you know what.

Even though this theory has life, it is not very believable, because people can see these symbols everywhere if they really want to.

6. Walrus and Carpenter are actually Buddha and Jesus.

This is the name of the poem that the twin brothers Tweedledee and Tweedledum read to Alice. The poem tells the story about Walrus and Carpenter, that walk on the beach and call out for oysters to walk with them. The oysters go to the shore and Walrus and Carpenter eat them. Walrus then cries at the end.

There are several interpretations:

  • Walrus is a caricature of Buddha, and Carpenter is Jesus. For example, the character Loki from Dogma believes this. The logic is simple: Walrus is fat and happy, so he is Buddha or elephant Ganesha, and Carpenter is the direct reference to the profession of the father of Jesus.
  • J. Priestly is convinced that the poem is the story of England’s (Walrus) colonization of America (Carpenter).
  • There is a more violent interpretation. Some people believe that Walrus and Carpenter are politicians that kill the masses — the oysters.

7. The poem about the White Rabbit in chapter 12 uncovers the love mystery of Carroll himself.

Some researchers see the reference to the unusual connection between Lewis Carroll and Alice Liddell that was the prototype of the main character. Here are the lines we are talking about:

He sent them word I had not gone

(We know it to be true):

If she should push the matter on,

What would become of you?

This is one of the most sensitive moments in the interpretation of the tale. Some people think that when the girl was supposed to come of age, the writer was going to marry her, but for some reason he had an argument with Mrs. Liddell and he never saw the members of the family since.

Do you want to read the tale now that you have some new knowledge about it in order to find some new hidden meaning? If yes, you can read the original manuscript written by Carroll himself here.

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What 20 Celebs Looked Like at the Start of Their Career

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Celebrities are usually known for their biggest successful works, but most of them stepped into the entertainment world with smaller roles. A lot of them have been in the industry for so long that we’ve forgotten what they looked like when they first started. Taking a look at some of their earliest works is indeed a blast from the past.

Bright Side looks into some of the earliest works from certain actors and is amazed at how much they have grown within the industry.

1. George Clooney

2. Dwayne “The Rock” Johnson

3. Keanu Reeves

4. Brie Larson

5. Betty White

6. Leonardo DiCaprio

7. Drew Barrymore

8. Tom Hanks

9. Scarlett Johannson

10. Halle Berry

11. Harrison Ford

12. Denzel Washington

13. Reese Witherspoon

14. Angelina Jolie

15. Johnny Depp

16. Jennifer Garner

17. Robert Downey Jr.

18. Will Smith

19. Nicole Kidman

20. Sandra Bullock

Have you seen the early works of these celebrities before? Do you know what any other famous entertainers looked like when they first began their career?

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