Driving through Hialeah, where strip malls line boulevards like concrete-and-metal kudzu, a federal agent offers a reporter $1 for every strip mall he can spot that doesn't house a medical business.
Let's just say the reporter is still broke.
In this city, streets are a jumble of doctors' offices, physical therapy programs, adult daycares, and mental-health clinics stretching in every direction. Mom-and-pop pharmacies proliferate despite being situated doors down from Walgreens.
Agents say — and prosecutions prove — that something suspicious has been going on. Many of these businesses provide no therapy, unnecessary therapy, or dubious therapy, then turn around and bill federal taxpayers for this "health care" through the Medicare program.
"They bring in these Zumba dancers," the agent cracks. "These young girls are Zumba-dancing away, and these old guys are looking at it, and, yeah, they're getting some kind of therapy."
Medicare fraud threatens to overtake drug dealing as America's favorite get-rich-quick pastime. The stealing has become so sweet that street criminals can easily pull in $25,000 a day without carrying a gun. Because the crime is so widespread, prosecutors don't even bother going after anyone unless they've stolen $500,000 or more. The few who are caught and convicted typically get only modest sentences, making Medicare fraud the criminal equivalent of saccharine.
Think of the Medicare program as a bank that never bothered to buy a safe.
When the program was established in 1965, it was set up to provide medical care to people over age 65 who typically could not afford private insurance. But founders of the program did not anticipate the changes that were to come — population booms, skyrocketing medical costs, prescription drugs, private insurers shunting unhealthy people. Nor did they anticipate the thieves of today.
In the idealistic 1960s, people generally knew their virtuous family doctor, and health-care fraud was such a secondary concern that Medicare fraud wasn't even officially made a crime until 1996. In the intervening decades, things changed.
First, some doctors were loath to accept Medicare patients because they didn't want to wait for the wheels of bureaucracy to churn; it was weeks before they'd receive checks in the mail for services rendered. So Medicare, looking out for its elderly patients, made it easier for them to receive care by approving more providers. The program made it simple for anyone who wanted to open an outpatient clinic or a medical supply company to get a Medicare provider number (technically, a ten-digit National Provider Identifier, or NPI) — the green light to start doing business. With this number, providers could start serving Medicare patients, then submit invoices to and get paid by the government. Many providers — like the ones that sold medical equipment, for instance — didn't need licenses, and there were no education requirements. Medicare started direct-depositing payments in doctors', hospitals', and providers' accounts almost as soon as bills were submitted. Before long, the tables were turned and health-care workers were clamoring to get those Medicare patients in the door — and receive the steady payments. Uncle Sam's checks never bounced.
Medicare's good intentions were exploited in a multitude of ways by a wide array of thieves, as detailed in this article. Because Medicare has traditionally paid invoices first and pursued criminals only after time-consuming audits ("pay and chase," insiders call it), the U.S. Treasury has bled like a hemophiliac — and South Florida is the gaping wound. In the past 20 years, everyone from HMOs to drug dealers has been caught robbing the program time and time again, stealing the kind of money that makes the sequester look like pocket change.
Given how often such blatant thievery goes undetected, no one's sure how much fraud there really is. Conservative estimates place the bill at $100 billion annually. The more adventurous peg the figure closer to $300 billion — three times what the feds spend on education. It has left federal health care little more than an unlocked home, where street punks and gangsters, doctors, and even states walk right in and help themselves to whatever's inside.
Though the government is finally making inroads into stopping this fraud with special teams of investigators and prosecutors, the federal agent driving through Hialeah says he's been working on health-care fraud for ten years — and he's sure he'll be working on it for ten more.
Warm weather attracts mold, mosquitoes, and retirees with government benefits. With the senior population conveniently warehoused in group homes and assisted-living facilities, it's no surprise that South Florida is the epicenter of health-care fraud. The examples are legion.
Let's start with Cuban expat Armando Gonzalez, who served five years for dealing crack. When he got out, he applied for and received a Medicare provider number and — ka-ching! — opened several outpatient psychiatric clinics in Miami.
Gonzalez teamed up with assisted-living facilities full of residents suffering from retardation and dementia. In exchange for kickbacks, operators of these facilities would bus in all their patients; Gonzalez would collect each of their individual Medicare card numbers and bill Medicare for services the "patients" weren't eligible for or never received.
By the time the feds started sniffing around in 2008, Gonzalez had made off with $28 million, enough to fund a personal fleet of 17 luxury vehicles. He closed shop in Miami only to reopen in North Carolina. When he was finally arrested last year, Gonzalez was planning to expand into Tennessee. He pleaded guilty in December.
Still, fraud knows no party, race, or gender. Indeed, allegations against state Rep. Daphne Campbell's (D-Miami) clan could script a health-fraud installment of The Klumps.
Campbell ran ten group homes until the state canceled her Medicaid contract in 2006. Four people died in her facilities that year, including one developmentally disabled female patient, who had also been raped. Inspectors found rodent feces and general squalor.
Meanwhile, Campbell's ex-con husband, Hubert Campbell, has been accused by two former partners of defrauding Medicaid (Medicaid is a state version of Medicare and serves the poor and disabled).
Not to be eclipsed, their 28-year-old son, Gregory Campbell, is accused of submitting nearly $300,000 in false Medicare billings while operating adult group homes. He's been charged with felony theft, organized fraud, and Medicaid fraud.
And just last week, Naples check-cashing store owner Oscar L. Sanchez was sentenced to 4.5 years in prison for stealing $10 million from Medicare and siphoning it to Cuba. Sanchez, who is Cuban-American, was allegedly part of a ring that falsely billed Medicare for $374 million.
The culture of fraud stinks to the very head of Florida government.
During the 1990s, the feds prosecuted the largest fraud case in Medicare history against hospital chain Columbia/HCA. The company seemed more organized-crime outfit than health-care provider.
Columbia billed for tests that weren't necessary or ordered, submitted false diagnoses to increase reimbursements, paid kickbacks to doctors for patient referrals, and billed for home visits people didn't qualify for or receive.
The smoking gun was the two sets of books Columbia kept. One detailed all Medicare submittals. The other noted which were fraudulent, allowing Columbia to keep enough reserves to pay penalties should it ever get caught. A whistleblower estimated that fraud alone accounted for more than one-third of the company's profits.
When the whip came down in 2003, Columbia settled for $2 billion in fines for "systematically defrauding federal health-care programs."
The man at the head of this company claimed ignorance and was eventually fired — but with the velvet landing accorded to disgraced CEOs. Rick Scott walked away with nearly $10 million in severance, stocks worth $300 million, and a $1 million-a-year consulting contract. In 2010, he was elected governor of Florida.
Only two lesser executives got jail time. Lead FBI agent Joe Ford would later regret allowing the company to simply pay away its sins: "People need to go to jail."
Florida may be an epicenter of Medicare fraud — but it's a problem all over the country.
At Michigan's Monroe Pain Center, parking lots were filled with cars sporting license plates from Kentucky, Tennessee, and even Florida. That's how far people were willing to drive for a "Las Vegas Cocktail."
The cocktail mixes Xanax, Soma, and Vicodin for a powerful opiate high. Monroe was its unofficial retailer. It was led by Oscar Linares, a doctor from the Dominican Republic. In 2008, the office went from seeing 40 patients a day to as many as 250. Over two years, Linares prescribed 5 million doses of narcotics. Traffic grew so heavy that he hired a parking-lot attendant. Workers got bonuses when the patient count topped 200 in a day.
The cost to Medicare: $5.7 million.
Linares rarely examined his patients. One undercover cop didn't see the doctor until his tenth visit, and only then via a television monitor. Linares' workers simply gathered patients' information and had them sign blank forms that would be filled in later. Then a guy who used to work at Lowe's would hand out the scrips.
When the clinic was raided in 2011, police seized $214,000 in cash, a yacht, and the 55-year-old doctor's fleet, which included a Ferrari Spider and a Bentley Continental. Linares was charged with unlawful distribution of prescription drugs and Medicare fraud. He has pleaded not guilty and is awaiting trial.
A half-hour north, in Detroit's Cass Corridor, amid a stretch of poverty and ruin called "The Beach," shelters provide a steady flow of poor Medicare beneficiaries. Recruiters drink beer and sit on beach chairs — hence the name — wrangling people into vans that shuttle "patients" to doctors, home-health agencies, and mental-health clinics.
Doctors not only bill Medicare and Medicaid but use the power of prescriptions as currency to pay accomplices. It's a multiring circus, with the doctor at its center and kickbacks flowing in all directions, to pharmacies, patients, and recruiters.
"A recruiter will identify a physician and work out a deal, saying, 'I'll bring you so many patients,' and the recruiter will pay a physician $10,000 to $15,000 to write scrips like crazy, pad after pad, for a week," says one Detroit agent.
"When you have a dirty doctor writing 500 scrips for Oxycontin a month, you have to have a pharmacy that is going to fill them. If a pharmacy sees a Dr. ABC's scrip 500 times a month, they will call and ask, 'What's up, Doc?' The recruiter plays a role here too and says, 'I'm taking care of the pharmacy.' "
The scheme has even spawned subspecialties such as "quality assurance" experts. They're typically former doctors from overseas who read through patient charts to flag anything that might prevent Medicare from paying.
And since frauds realize that Medicare auditors see red flags when there's a billing spike from one company, they'll incorporate seven or eight to spread the grift. Some even launch check-cashing businesses to launder their money.
"Now we're seeing people who aren't doctors open these clinics and hire other dirty real doctors to 'work' in the clinic," says the Detroit agent. "Almost every day, there's a new thing."
Like many states, Minnesota pays HMOs to administer its Medicaid programs. But David Feinwachs, an attorney for the Minnesota Health Association, a trade group for the state's hospitals, noticed something odd. While actual providers had seen their reimbursement rates frozen for more than a decade, HMOs were hiking their management fees 10 percent a year just for playing middleman.
So Feinwachs started examining the HMOs' finances. "Because they're nonprofits, nobody ever looks at them," he says. "It's the perfect cover, because everybody goes, 'They're nonprofits. What's the problem?' "
He soon found they'd turned Medicaid into a cash cow, making it several times more profitable than their private insurance. But when Feinwachs asked for more data on their costs, the state blocked him, claiming it was proprietary information.
He was outraged. "You can't take tax-funded programs, turn them over to vendors, and claim that what happened to the money is a trade secret."
He also found evidence that HMOs were overbilling Medicare to cover for cuts in its state Medicaid program, thus making every taxpayer in America chip in for Minnesota's duplicity. Two months later, Feinwachs was fired for insubordination.
Though Congress eventually began investigating his claims and multiple investigations continue, Feinwachs remains unemployed. He now spends his time agitating for reform.
"The interesting thing about health-care fraud is that our government always goes after low-hanging fruit," he says. "If they were storekeepers, we'd put in surveillance systems and armed guards to catch kids stealing gum from around the cash register. Meanwhile, we have people backed up to our warehouses with semitrailers loading the merchandise, and we're oblivious to that."
Some of the Medicare fraud is so ridiculous, it's hard to believe. Take Armen Kazarian, kingpin of Los Angeles' Armenian Mob. The feds say his gang stole the identities of doctors and patients while setting up fake clinics across the country. They knew nothing of medicine, sending Medicare fake bills that showed eye doctors doing bladder tests, obstetricians testing for skin allergies, and dermatologists billing for heart exams. Medicare paid out $163 million before Kazarian and 73 henchmen were caught by the FBI. In February, Kazarian received a sentence of just three years.
Not all schemes are this flamboyant. Some simply employ sleights of paperwork. A Detroit podiatrist billed Medicare $700,000 for performing toenail removals that amounted to little more than toenail clipping. Two Miami doctors billed back rubs as physical therapy, taking in $57 million. In 2009, private ambulance services in Harris County, Texas, billed Medicare $62 million for emergency shuttles. By comparison, New York City received $7 million for the same services.
Some scams are so brazen that they advertise on TV. Remember those late-night Scooter Store ads, promising to get you a motorized wheelchair "at little or no cost to you"?
In 2007, the San Antonio company agreed to pay $4 million in civil fines and forfeit another $43 million for advertising one scooter but delivering a more expensive model on Medicare's dime.
Executives didn't learn their lesson. The Scooter Store was soon caught again, this time for overcharging Medicare by as much as $87.7 million between 2009 and 2011, according to an audit. But the federal Centers for Medicaid & Medicare Services (CMS) agreed to a spectacularly lenient settlement, allowing the company to repay just a quarter of that figure.
The feds would get tough only after CBS aired an investigation illustrating how the company browbeat doctors into writing unnecessary prescriptions for scooters. They raided Scooter Store headquarters in February. It finally appears the company has been barred from federal health programs.
The sad thing about Medicare fraud is that it ends up hurting the people it was initially meant to protect — society's weakest. It also taints the people standing up for them.
Because it treated Texas' poorest citizens — its mentally ill, its drug-addled — Houston Riverside General Hospital, a 95-year-old nonprofit formerly known as Houston Negro Hospital, was at one point losing $10,000 a day. That's when executives decided to cauterize the wound with a hot poker of fraud.
In 1996, the State of Texas accused Riverside of padding fees and billing for drug rehabilitation services it never provided. Texas canceled $1 million in contracts and demanded that the hospital repay $763,000 more. It also urged the feds to audit Riverside's Medicare and Medicaid payments.
Yet charges of fraud weren't enough for bureaucrats to fully close the spigot. The money continued to flow. It would take another eight years before the state had finally had enough. In 2004, it moved most of its drug-treatment contracts to more trusted providers, slashing Riverside's funding by 75 percent.
Congresswoman Sheila Jackson Lee tried to look like a hero as she cried to restore the money for the poor. Gov. Rick Perry obliged with another $3 million.
It wasn't until 2011 — 15 years after the initial accusations — that law enforcement got serious, prompting an administrator, Mohammad Khan, to confess to enriching the hospital through a kickback scheme. He'd been paying "recruiters" $300 a head to bring Medicare patients to Riverside's six psychiatric clinics. They arrived by the van-load for daily therapy sessions they rarely qualified for or received. Medicare picked up the $116 million tab. Only when this scheme was discovered did the CMS finally halt the hospital's payments.
Good congresswoman Jackson Lee again rode to the hospital's rescue. "Even if more harmful acts prove to be true," she wrote to CMS, "an entire institution should not be penalized by the acts of one person."
In Riverside's case, that "one person" would abruptly multiply. Khan ratted out CEO Earnest Gibson III as his co-conspirator. The feds also nabbed Gibson's 35-year-old son, Earnest IV. He ran one of the psychiatric clinics and was charged with billing nearly $700,000 for care that "was not medically necessary and, in some cases, not provided," according to prosecutors.
Investigators discovered that, since 2005, the hospital had been swindling the feds to the tune of $22 million a year. Khan pleaded guilty. The two Gibsons and five others await trial on charges of fraud, conspiracy, and money laundering.
Jackson Lee refused to comment for this article.
Housed in a featureless building north of Miami, the HEAT Task Force is a government anomaly: It actually turns a profit.
For every dollar it spends investigating, it uncovers another $8 in fraud. Most agents work out on the street, assigned to about a dozen cases each.
In 2007, the government finally grasped the scope of all the stealing and got serious about trying to stop it. The Department of Justice launched Medicare Fraud Strike Forces in Miami and Los Angeles. Those were supplemented with HEAT teams (HEAT is short for the windy governmentese of Health Care Fraud Prevention and Enforcement Action Team) in 2009. This group — an interagency initiative combining members of the Justice Department and Health and Human Services — has branches in nine cities where the stealing is most prolific, such as Los Angeles, Houston, New York, Dallas, and Baton Rouge. Agents and prosecutors work in small, aggressive teams, combining data analysis with traditional detective work.
Since 2007, prosecutors have charged 1,480 defendants with $4.8 billion in fraud. More than half of those indictments came out of the unit in Miami, a city that Special Agent in Charge Christopher Dennis calls "the crown jewel of Medicare fraud." Miami was the MIT of health-care schemes, the nation's unofficial laboratory for ripping off the government. "A lot of the schemes are typically started here — vetted, proven here — and farmed out to other parts of the country," Dennis said.
At first, the Justice Department mostly tackled companies that sold medical equipment — scams involving wheelchairs, hospital beds, respiratory devices, and the like. Lax oversight allowed these businesses to pop up overnight, bill Medicare for hundreds of thousands of dollars, then disappear just as quickly — only to reemerge elsewhere under a new name. Often, perpetrators had fled the country with the stolen funds before indictments could come down.
Hank Walther was a federal prosecutor who led the feds' Medicare Fraud Task Force. He feels they were allowing their adversaries to run scot-free.
"My 4-year-old kid could prosecute these cases," he says of the equipment rackets. "They're really easy, and there are plenty of them. A lot of this other stuff — home health, the ambulatory cases, even the mental-health cases — each time we got into those new areas, there was a constant refrain from law enforcement and the U.S. Attorney's Office saying, 'This is too complicated.' "
The feds started teaming prosecutors with detectives in the same approach used to break down organized crime. They began to hunt providers, whose fraud ran to the tens of millions compared with the $1 million to $2 million paydays from equipment scams.
"When you look per capita, Miami has more people in community mental-health centers than New York and Los Angeles combined," says Walther. "Then you look at the profile of people going in there, and they don't really fit people that need these services."
In 2010, Walther helped take down American Therapeutic, the highest-billing mental-health center in the country. The company was cycling addicts, alcoholics, and Alzheimer's patients through its six clinics. Patients' diagnoses were changed so they would qualify for expensive group therapy. In the end, owner Lawrence Duran received an unheard-of 50 years, a sign that judges were finally acknowledging the magnitude of these swindles.
"It's like Whac-A-Mole," says Walther. "You knock one down, but now there's a bigger one somewhere else, and it's different. But once you figure it out, it rains on the back end with bad guys and money."
HEAT Agent Reginald France, a first-generation Haitian-American built like a linebacker, was out at 3 a.m. recently raiding a medical office. His motivation comes from the guile of these crimes.
"You have some of the smartest people in law enforcement working here," he says. "In a lot of ways, that drives us, because we want you to understand you can't pull the wool over our eyes."
Elderly Medicare recipients are crucial to the schemes. Instead of stealing patients' Medicare numbers, which are needed to submit invoices to Medicare, frauds pay the elderly in kickbacks. Recruiters typically pay beneficiaries a combination of cigarettes, booze, pills, and money. Cash payments can reach $2,000 quarterly. All recipients have to do is sign sheets confirming that care was received.
For the patient, it's a low-risk play. Nobody wants to put an 80-year-old meemaw in front of a jury. Prosecutors wouldn't recoup much even if they did. And since by law Medicare can't be revoked, there's little downside to bartering your number away for a carton of Kools.
"That's the bread and butter of the fraudster — the fact he can pay somebody to participate in the scheme," says Dennis. "If you have a willing participant, you then eliminate the ability to tie the fraud to you. That person is going to lie for you because they conspired with you."
"All of these prosecutions are great," says Louis Saccoccio, CEO of the National Health Care Anti-Fraud Association. "We have strike forces, but the prosecutions just tell you we have a big problem, because that means the money's already out the door. So the focus now is starting to shift to prevention."
President Obama has expanded the task forces and made fighting fraud a pillar of the Affordable Care Act, otherwise known as Obamacare. CMS was given greater discretion in suspending payments and screening providers before they entered the system. Penalties and prison time were also increased.
But excuse congressman Michael Burgess' skepticism. The Tea Party Republican from Texas has heard such talk before.
The former gynecologist is willing to concede that progress has been made. Yet the sheer size of the task makes crime-fighting difficult. Every day, Medicare contractors process 4.5 million claims. Even Republicans admit that CMS is undermanned and forced to rely on contractors, whose ferreting out of fraud is inconsistent at best.
"There was a famous case here in Dallas where a Nigerian woman had been busted," Burgess says. "As she was going off to jail, it was discovered that she had several other provider numbers. They discovered that she was receiving checks at the same post office box. It never occurred to anyone that, 'Hey, anything that goes to P.O. Box 9058, that's a red flag.' We were probably paying for her defense."
In New York, centers for people with mental issues were charging the feds $5,000 per day per patient. Arizona, by comparison, charges $200 a day. The reimbursements were based on a changing formula that CMS kept approving even as payments skyrocketed. New York's estimated overcharges: $15 billion. Even though CMS discovered the state's gouging, six years later, it's still negotiating a remedy. CMS now plans to let New York phase out its overbilling, essentially allowing the state to steal a little less each month. (CMS officials declined to be interviewed for this article.)
More obvious improvements still elude the agency — even such basics as changing a beneficiary's Medicare number when theirs is stolen or used in a fraud. Others wonder why CMS hasn't mimicked credit-card companies, which flag suspicious behavior within minutes.
"I sent my staffer to Chick-fil-A with my personal credit card to charge $100 of sandwiches for our office for lunch," says Burgess. "So I'm called off the floor of the House to answer a phone call from my credit-card company saying, 'Hey, someone is trying to charge $100 worth of sandwiches.' Why can't [Medicare] do that?"
Obamacare has allocated $100 million to CMS to create a similar computer system that would employ data analytics to flag suspicious claims as soon as they're billed. The new proactive stance includes a spiffy command center in Baltimore linked to field agents. In its first full year, the system identified or prevented $115 million in fraud.
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But as Burgess notes, Obamacare provided CMS with "seven new tools" to fight fraud. Four years after the law passed, CMS has managed to enact just one.
"At this rate, some point before my natural death, maybe we'll have done half of them," says the congressman.
Though most everyone agrees that the government is moving in the right direction, $100 billion continues to walk out the door each year.
"This is a lucrative business, and business is good," says Feinwachs. "The only problem is that you and I are funding it."