It’s A Miracle, I’m Sick!

“Because that’s where the money is.”

Willie Sutton

Be it a bank or a liquor store, that’s where the money is! Theft is an art form. Bank Robber extraordinaire Mr. Willie Sutton understood that robbery is more rewarding when the target is swimming in cash.

If Mr. Sutton grew up today, he would likely target to rob health insurance systems. The reason: “because that’s where the billions of dollars are!” In 2024, per the U.S. Department of Justice, $2.9 billion dollars in settlements and judgments occurred under the False Claims Act.

To rob health insurance systems, Mr. Sutton would simply have to disguise himself as a stakeholder- a patient, a medical provider, or a health insurance employee. It must be appreciated that all of the stakeholders can contribute to the industry’s dysfunction and corruption.

In a previous post, an organized patient fraudulent scheme was detailed. It involved the NBA’s health and welfare program intended to assist with retired players. This Post shifts to the medical profession as the culprits. In this instance, a doctor not only ripped off the health care system, he also made his healthy patients sick.

Why should this be your concern? When any of the stakeholders rob a health insurance system, they create a variety of problems. Not only do they increase insurance costs, they also create longer queues for care and testing. Your MRI test may be delayed because a bogus MRI tests have been scheduled ahead of yours. Insurance company anti-fraud measures may also cause delay or denial of legitimate treatment requests.

Dr. Feel Bad’s Story

In Texas, a Rheumatologist “falsely diagnosed patients with rheumatoid arthritis to defraud Medicare, Medicaid, TRICARE, and Blue Cross Blue Shield.” Dallas Express (Note: he defrauded four different types of health care insurance.)

His scheme amounted to $118,000,000.00, in health care fraud. Essentially, he took healthy people, labeled them sick, and ran them through various unnecessary testing and procedures.

The most evil done he alleged did was that some of procedures involved exposing his patients to harmful side effects. The Dallas Express article noted that “[t]he unnecessary treatments caused severe side effects, including strokes, jawbone necrosis, hair loss, liver damage, and debilitating pain.” The Good Doctor also falsified medical records.

Conclusion

The reality is that health insurance industry bad acts are not limited to health insurance companies. Rather, all stakeholders can abuse the system. The reason why every stakeholder can be on the take is something that Mr. Willie Sutton realized long ago. With health insurance system fraud- “that is where the billions and billions of dollars are!”

Be well!!

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