Anatomy of a healthcare scam

A greedy businessman plus greedy doctor equals lots of expensive blood tests.

“Put your phone on top of my car!”

You might expect to hear this from a criminal who was just making sure that no one could listen in to his private conversation, and in this case, you would be right.

But this was no ordinary drug deal or covert mob transaction. Instead it was a request made by a very affluent physician to a salesperson.

“He asked me to take my phone and put it on top of his car, a nice car at that; I believe a Mercedes C Class. I guess ’cause he thought I might record what he was going to ask me for,” Mr. X, a salesperson for a blood lab company, would later tell me as part of his tale of greed and duplicity.

The physician in question, let’s call him Dr. Money, was having some trouble paying his bills for his $100,000 car, the kids’ schools, and especially for both his wife’s and mistresses’ needs and he wanted to offer Mr. X a deal that would make both of them “lots of money.” He just wasn’t sure if Mr. X was interested in his proposition or if he might even record their conversation.

Dr. Money wanted to continue to send his patients’ bloods to the salespersons’ lab but told him that he was offered $5,000 in cash a month, to use another lab.

“I like you and I have been very loyal to you, so if you match what they are going to give me I will continue sending you labs and even send you more than before,” Dr. Money told my source.

Mr. X did on occasion do favors for his clients and provide them with small fees to speak at dinner conferences, but this request, which if he agreed to could land him in jail, was something he had to decline. Almost as quickly as the doctor’s eight-cylinder German coupe could vanish, so did his account.

As the pharmaceutical industry became more scrutinized by the media and the FDA, it has become more difficult for the crooks with an MD after their name to find ways to profit without laying a hand on a patient. While reimbursements to physicians have fallen significantly, reimbursements for blood tests, especially complex blood analyses like allergy tests, hormone levels, and sophisticated rheumatologic tests, can be quite significant — as much as a few hundred dollars for each exam.

The simple mathematical equation of greedy businessman plus greedy doctor equals lots of expensive blood tests, is now more common than the public or the regulators realize. I suspect billions of dollars of inappropriate blood tests are being performed though arrangements like that of Dr. Money’s.

During the past few months, through interviews with salespeople, like Mr. X, and my own encounters with patients who visited with these duplicitous MDs, I have uncovered a scam that is likely costing insurers and tax-payers billions.

Some blood labs appear to be paying doctors cash to sign up with their lab and in return these doctors are given a list of tests that they should order on their patients — usually unnecessary studies that can cost thousands of dollars for each patient.

Unfortunately it appears that Medicare and many insurers, provided the right diagnostic code is submitted, pay for these tests.

Nothing illustrates my point better than the following case I recently witnessed.

Mr. P, an otherwise healthy man about the age of 40, wasn’t feeling well, or sleeping well, and he was very anxious and complained of feeling tired and of being very nervous and had lots of body aches that included a vague and constant chest pain. Worried that something was wrong, he sought care with a local doctor, a doctor like Dr. Money, who enhanced his profits in a way honest physicians would not; a doctor that seemed to order every allowable test, even if he wasn’t trained to do them; a man who likely made some illegal backroom deal like Dr. Money had with an opportunistic lab company: I send you blood tests and you give me cash.

When Mr. P noticed the bills submitted to a local blood lab, he recalled reading my book and sought me out to review his care. He brought all his records and bills for me to review. He told me that he finally left the care of his doctor after being prescribed thyroid hormones, even though his thyroid labs were normal. He was upset that this doctor had prescribed a medication that he did not require, as he later learned when he saw a thyroid specialist, and that he had ordered blood tests that his insurance paid thousands of dollars for.

Here are the actual labs tests ordered on Mr. P:

  • Thyroid  ProfileT4,
  • Free Thyroxine,
  • TSH,
  • T3 Uptake,
  • T3 Total,
  • Free  T3,
  • FT4 Index,
  • Thyroid Peroxidase AB,
  • Thyroglobulin  Antibodies,
  • Thyroglobulin,
  • Diabetic  Profile,
  • Glucose,
  • Glycohemoglobin,
  • Insulin,
  • C-peptide,
  • Hepatitis  Profile,
  • Hepatitis A Total,
  • Hepatitis A IGM,
  • Hepatitis B Surface AG,
  • Hepatitis B Surface AB
  • Hepatitis B Core AB,
  • Hepatitis B Core AB IGM,
  • Hepatitis C AB,
  • Comprehensive  Metabolic,
  • Endocrinology,
  • FSH,
  • LH,
  • DHEA-Sulfate,
  • Prolactin,
  • Progesterone,
  • Estradiol, Testosterone,
  • Beta  2 Microglobulin,
  • Free Testosterone,
  • Estriol Serum Total,
  • Sex Hormone Binding,
  • Globulin,
  • Hematology,
  • Sedimentation Rate,
  • Serology,
  • Anti-Streptolysin C-Reactive Protein,
  • RPR,
  • ANA Screen,
  • Anti DNA,
  • Herpes Simplex Type 1,
  • Herpes Simplex Type 2,
  • Rheumatoid Factor,
  • Cyclic Citrulline IGG,
  • Compliment C3,
  • Compliment C4,
  • Tumor Markers,
  • CA 123,
  • CEA,
  • AFP tumor marker,
  • PSA,
  • Free PSA,
  • % Free PSA,
  • CA 19-9,
  • HIV-1 AB,
  • HIV-2 AB Alergy tests.

For this 41 year-old fit man I would have ordered the following: Chemistry, Blood count – I did not notice if that was ordered Thyroid lab that would have only included a T4 and TSH for screening Lipid profile — I did not see that test ordered.

With just a few vials of blood, that took less than a minute to draw, thousands of dollars of inappropriate tests were generated.

Some reading this will be shocked and others upset and suggest that I have fabricated this story, but it is real and endemic in some areas. You’re not likely to find these meretricious acts in affluent towns or at university hospitals and I’m guessing many physicians, perhaps because they are sheltered or naïve, will take offense to what I have written. But go into an office in one of the working-class areas of a major city and you may find a physician all too willing to be an accomplice to this scam. I’m willing to bet there are thousands of doctors and hundreds of these smaller labs, ripping off billions of dollars from private and government funded healthcare. Billions!

While many insurers now require doctors to obtain their approval (a tedious and difficult process that creates a horrible working environment for honest physicians), it would be impractical for them to ask doctors to get approval for every single blood test, and just about impossible. And so… this is now a favorite ploy used by the worst of the worst, in my profession, to get rich, again.

But people are beginning to talk and the honest salespeople, who work for honest labs, know which labs and often which doctors are involved in this criminal scheme. If government could make it both easy and rewarding for anyone to report this type of crime, and if the laws had teeth and law enforcement were bold enough to parade these doctors and business owners in front of cameras just before they were incarcerated, then I suspect we could significantly reduce or virtually eliminate these kinds of criminal shenanigans and in the process save our healthcare system precious money.

Dr. Levine is a cardiologist who lives in Ridgefield and is the author of “What Your Doctor Won’t (or Can’t) Tell You: The Failures of American Medicine — and How to Avoid Becoming A Statistic.” Questions for this column may be e-mailed to him at [email protected].

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