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The move was so mysterious that Congress summoned UCare CEO Nancy Feldman to explain. She admitted that Minnesota was pumping up its Medicaid reimbursements to cover losses in a state program that Medicaid doesn't reach.

Just one small problem: Republican governor Tim Pawlenty had canceled that program a year earlier. Neither the state nor the HMOs bothered to tell the feds they were still covering losses from a program that no longer existed.

"How do we know that other state, private and personal interests are not being funded through the federal Medicaid program?" Republican representative Michele Bachmann asked when testifying before Congress. "The answer is, we don't."

David Feinwachs found that HMOs in Minnesota had turned Medicaid into a cash cow, making it several times more profitable than their private insurance.
Courtesy David Feinwachs
David Feinwachs found that HMOs in Minnesota had turned Medicaid into a cash cow, making it several times more profitable than their private insurance.
Texas U.S. Rep. Sheila Jackson Lee carried water for Medicare swindler Riverside General Hospital.
David Ortez
Texas U.S. Rep. Sheila Jackson Lee carried water for Medicare swindler Riverside General Hospital.

Multiple investigations are ongoing.

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 semi-trailers loading the merchandise, and we're oblivious to that."

Well, not everyone is oblivious.

The Guys Who Showed Up

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.

From the moment you enter the office, you notice something's different. The cubicle plantation is eerily quiet. Most agents are on the street, working more than a dozen each.

HEAT is short for the windy governmentese of Health Care Fraud Prevention and Enforcement Action Team. It has branches in nine cities where the stealing is most prolific — places like 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, they've 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," noting that "a lot of the schemes are typically started here — vetted, proven here — and farmed out to other parts of the country."

There's no shortage of targets.

Agent Reginald France, a first-generation Haitian-American built like a linebacker, was out at 3 a.m. this morning 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."

France takes a reporter on a tour of the fraud hotbed of Hialeah. Strip malls line boulevards like concrete and metal kudzu. An agent who wishes to remain anonymous rides along, his square jaw and disarming manner reminiscent of The Rock. He offers $1 for every mall without a medical business the reporter can spot.

It isn't easy.

There are doctors, physical therapists and mental-health clinics in every direction. Mom-and-pop pharmacies sit just doors down from Walgreens, yet they out-bill the national chain thanks to prescription drug fraud. Adult daycare centers specialize in physical therapy for Medicare beneficiaries.

"They bring in these zumba dancers," cracks The Rock. "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 recipients are crucial to these schemes. While it's possible to simply steal patients' information, those schemes are easier to detect.

"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."

Recruiters typically pay beneficiaries a combination of cigarettes, booze, pills and money to use their Medicare numbers. 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 eighty-year-old mee-maw in front of a jury. Prosecutors wouldn't recoup much even if they did. And since Medicare can't be revoked by law, there's little downside to bartering your number away for a carton of Kools.

This makes the beneficiaries key to unraveling the plots, and necessitates a careful, respectful touch. Many of The Rock's tips come by way of recipients he's encountered in previous cases.

The Rock savors breaking down liars. He asks them seemingly innocuous questions about their family and upbringing. These are typically answered in a quick, sure tempo, while questions of fraud are littered with ums, wells and false starts.

"You keep them talking, and after a while, their house of cards starts to crumble," he says. "They're looking up and noticing that I'm not writing down anymore. You give them the look — 'I'm not stupid' — the same look their mother and my mother gave us."

He's been chasing fraud for more than a decade, and he's sure to be doing it a decade from now. The wonderful thing about the federal government being your mark: It always has new money to steal.

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2 comments
Juan_Leg
Juan_Leg

It's nearly destroyed 'Pain Management' in Colorado . The absolute WORST culprit in this entire health care melt down was of course Dr. Clemmons, and the damage he has done is NEARLY irreversible !

I'm an amputee who has survived being run over by a train as well as hit by a car twice . I keep ALL my records/tests up to date, but CAN'T find a Doc who specializes in pain, & trusts ANYONE ! I was NEVER one of Clemmons' patients & did NOT play games w/ my pills EVER ! Nor was I EVER accused or investigated !

I'm SO close to quitting what little I do get now & returning to on going binge drinking . This coming after quitting drinking YEARS ago ! 

I AM BEING FORCED TO SELF MEDICATE W/ ALCOHOL !!!

 
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