As a healthcare ethics keynote speaker and healthcare ethics consultant, I convey to my audiences that acts of fraud needn’t be dramatic (such as widespread illegal opioid script payoffs to physicians). Healthcare fraud can occur “drop by drop,” and undercover. In fact, healthcare fraud is not necessarily the domain of healthcare providers, but any unethical person with a knowledge of the healthcare system seeking to take advantage of others.
The Raleigh NC Investment Advisor
The following report was filed on October 24, 2022 by Ashley Anderson of WNCN in Raleigh, NC. Anderson reported on an investment advisor in Raleigh who submitted more than 5,000 false Medicare claims. He defrauded the government out of nearly $535,000.
The perpetrator of this fraud was found guilty of “conspiracy to commit healthcare fraud, healthcare fraud, wire fraud and aggravated identity theft.”
The defendant and a co-conspirator submitted fake claims “for mental health services that were never provided to about 145 alleged beneficiaries.” It was a fake claim “mill” that relied on the investment advisors to steal the identities of a vulnerable population. Many were elderly and indigent.
From a creative standpoint, I must admit they were immoral geniuses. According to the news report, in some situations, “Ford’s company offered services such as electronic conversions of health records or teletherapy counseling to assisted living homes for elderly individuals and people with disabilities.”
As part of this so-called conversion, they stole the identities of those who could barely afford to take care of themselves. In other situations, the investment advisor’s company offered free groceries in exchange for Medicare. These were elderly parishioners of churches, who didn’t realize what was happening to them.
Though the investment advisor may face a sentence of more than 50-years in jail.
Flaws in a flawed system
As a healthcare ethics keynote speaker and healthcare ethics consultant, I have a grasp of the immensity of the Medicare system and how it is possible to use the system to not only cheat the “organization,” but the most vulnerable in our society. I might add that during and after the pandemic the Raleigh-area was subjected to numerous cases of Medicare fraud. We might argue that Raleigh had loose controls, or tight prosecution.
In this particular case, the defendants stole the Medicare information, submitted the claims and then pocketed the money. The case, originally adjudicated in 2020, by the DOJ of the Eastern District of North Carolina, tracked the illicit activities back to 2018. Once the claims with stolen information worked its way into the system, it became a continuous flow of funds.
Whether a whistle blower, the relative of a duped individual or a Medicare investigator who finally uncovered the fraud, isn’t clear. What is clear is that Medicare, plagued by years of fraudulent activity is flawed. I don’t consider for one moment that Raleigh is the only place in the country where this sort of fraud occurs. In 2021 alone, an astonishing $5.6 billion in Medicare fraud was uncovered by law enforcement.
From an ethical point of view perhaps the greatest vulnerability of the system must start with the most vulnerable. It breaks my heart that the disabled and elderly are being defrauded by people such as this investment advisor.
Rather than politicians and legal minds acting alone on these problems, maybe it is long past due for those involved in ethics to get involved. Second, how can patient information be better protected. If my credit card is misused, I am generally notified by the issuer. Can the card number be encrypted or require a more elaborate verification?
It is time many more questions need to be asked of the system because the fraud itself continues unabated.
