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The Best Fraud Story Ever: The Top 10 From The NHCAA

The Best Fraud Story Ever: The Top 10 From The NHCAA

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Stolen wheelchairs, stolen prosthetic limbs, the mafia, over-billing, up-coding, 72 hour work days, sham clinics, the dog ate my medicine and a dead man in the freezer- we've heard it all, and it wasn't made up! At the NHCAA Healthcare Anti-Fraud Training conference in Las Vegas, we asked attendees to share their best fraud stories with us. They came and they told! We were amazed with the variety of stories we were presented. Here are a few of our favorites from the training conference, in no particular order:

1. The Dead Man in the Freezer

A call was received from a detective to verify a life insurance policy. The individual had healthcare and prescription coverage, but not life insurance. The member had recently died, ending their pension payments. The member's life partner realized that the pension payments would stop now that the member was dead, so he wrapped his body in duct tape and put him in the freezer. His death went unknown and the money kept coming in. The house had "flooded" and the person told the plumbers to focus on the pipes and to leave the freezer alone. There was a towel that had frozen to the freezer because of the water. The plumbers went to remove the towel, the lid came up with it, exposing the dead man inside. Plumbers called the cops expecting foul pay, the member's partner was charged.

2. The Dog Ate My Medication

A home health care nurse was responsible for delivering and administering medication to a group of clients twice a day, while also conducting patient evaluations. One client in particular gave a testimony after reporting that the nurse hadn't been giving her the medication (even though the nurse was billing for the services) and that her dog had eaten it. She reported that the nurse dropped the meds through the mail slot, they were left on the floor and the dog ate them. The vet confirmed this, as the dog was full of its owner's drugs.

3. Someone Stole My Prosthetic Leg

A call was made into a company's hotline regarding a lot prosthetic leg. The complainant claimed she thought the garbage man stole the leg because she thought she had left it out by the trash.

4. Doctor and Patient Impersonations

Some companies were created in India to scam insurance companies by using servers in the US to scramble phone numbers and call locations. The people making the calls were impersonating doctors, patients and other staff members in order to confirm services and have payments pushed through.

5. I Didn't do it With Fraudulent Intent!

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This was an SIU case where a lady had called in after receiving a hospital bill, billing her for an extra day. That extra hospital day happened to be the day of the funeral for the woman's son. Her medical history was reviewed and what was happening was that the hospital had billed her on Saturday for services she received on Wednesday. The hospital had been billing anyone who received those particular services the same way in order to get reimbursed from the provider. The person in charge of billing stated they didn't mean to do it with fraudulent intent- although, to me it seems like billing someone on the wrong day for services rendered is pretty intentional.

6. Clipping Toenails = Surgery?!

There was a podiatrist that had committed a number of different types of fraud, but the one they commonly used was up-coding. The podiatrist would travel to nursing homes and complete basic procedures such as clipping toenails. Rather than billing for the basic services, the podiatrist billed patients for different types of surgery. Two patients billed for certain type of foot surgery were both double amputees, which eventually lead to the podiatrist getting caught.

7. A Bad Address and a Whole Lotta Wheelchairs

There were many suspect providers operating out of a known "bad" address, including a particular physician assistant (PA). 76% of the provider's beneficiaries received power wheelchairs. The provider supervises the PA mentioned above. Almost half of the provider's Medicare patients resided in central or northern California, and they practiced in Los Angeles. When the beneficiaries were interviewed, it was revealed that many of them had been solicited to have unnecessary medical services performed in exchange for free food, power wheelchairs, free transportation to the clinic (some were a 5 hour + drive away) and other DMEs. The PA began working for two other doctors at another known bad address in LA, and started committing the same types of fraud as mentioned earlier. During the practitioner interviews, one practitioner stated that they were paid $6-8 000/ month to come in once a week and sign charts. The PA returned to work at the first bad address above. Eventually the scheme fell apart when doctors were contacted and stated they didn't place the orders and weren't aware that their names were being used. The case is currently under investigation.

8. Sham Weight-loss Clinic: Your Worst Nightmare

A weight-loss clinic was advertised in California, promising a free flight and treatment covered by Blue Cross plans. At the clinic, doctors falsified records and diagnoses to get payments for things that weren't covered under the healthcare plans. In the case of one particular client looking to lose some weight, he arrived at the clinic, which happened to be a psychiatric hospital in a run-down section of Bellflower. Doctors diagnosed him with bulimia and psychotic depression, two things the client denies ever having. It gets worse- he was told he couldn't leave. The scheme got so large, with the company allegedly billing $100 million in services. The "patients" were sent on shopping trips and to local attractions, with the activities being billed as things such as "life skills therapy."

9. Faking Cancer

A lady was found guilty of faking cancer for two years. The woman had a medical background, therefore she used her knowledge to "beat the system".

10. I'll Pay, I Don't Want to go to Jail for This

Another podiatrist story! This time the podiatrist billed using a code for a joint survey that they apparently conducted on every patient they saw. The code was rarely ever used, and most podiatrists had never even heard of it. The joint survey consisted of x-raying 2-3 joints, commonly looking for Rheumatoid Arthritis- something podiatry patients wouldn't be examined for. When the podiatrist knew he was caught, he said he would rather pay than go to jail.  He paid the total that was falsely claimed, coincidentally, Medicare was coming to his office that afternoon to investigate.

Thanks to everyone who stopped by, chatted and shared their stories with us. We've had such a great response and heard so many stories, we invite you to add your own fraud stories in the comments section below. I look forward to reading your best fraud stories ever.