Investigating Doctors who Overprescribe
My grandfather was a doctor, working until he was eighty years old as a family practitioner in the same Detroit hospital for five decades. He died of cancer two years after retirement in a dingy room in the very hospital he’d served in. He’d never gotten rich, and did house calls for free because that’s what a good doctor did. I admired his black leather medical bag, the size of a pumpernickel loaf, packed with the standard knee-knocker, silver stethoscope, blood pressure kit, and small pack of Lucky Strike cigarettes that sustained him and, eventually, quietly tucked him into death.
Today I spent four hours investigating a two-thousand page medical file full of red flags for doctor fraud. The doctor’s patient, a dishwasher, had alleged eighteen body part injuries in a Cumulative Trauma claim resultant from one year of work. What the rest of us call soreness and fatigue, the patient had been calling a disability, but the real culprit became the patient’s doctor, who immediately prescribed five medications (three narcotic pain killers, one muscle relaxer, and one tranquilizer), eventually ordered eleven different MRIs in-house, and scheduled a re-examination every two weeks.
All the patient had to do to continue getting his disability checks was show up for the unnecessary MRIs, comply with physical therapy, and keep taking his pills. If a urinalysis showed no drugs in his system, the insurance adjusters would stop his payments under the assumption that his pain was no longer real.
The patient wanted his disability checks, so he had to take the drugs. And yet, none of the patient’s MRIs had been remarkable beyond their padding of the doctor’s bottom line at five grand a pop.
After a few months, the doctor had groomed a steady income stream: The patient had become an addict from the over-prescribing of narcotics, returning to the doctor for refills and exaggerating his pain to get the higher doses appropriate to his strengthening addiction.
Stronger pills were prescribed, more MRIs ordered, and the patient eventually suffered from real physical ailments that needed treating. The bilateral shoulders, the bilateral knees, the bilateral wrists, and the gastrointestinal problems he’d originally claimed had now become amplified as a consequence of the body breaking down from the narcotics in his system, and from the lifestyle that comes with taking them.
Doctor fraud — milking the insurance companies, for starters — is easier to suspect than to prove. In assisting with a conviction, an investigator must identify “intent.” Did the medical provided mean to order unnecessary MRIs and turn his patients into drug addicts, or was he just bad at his job? Wasn’t the patient exaggerating ailments so he could take a break from work, and the doctor simply rooting for a diagnosis?
Or, was the doctor taking advantage of a classic co-culpability scam, letting the patient lie to him so that the doctor could lie to the insurance company in return? Those second homes, rental investments, and Audi Q8s don’t come cheap, after all.
In contrast to proving doctor fraud, it is often easy for insurance companies to prove that a patient is exaggerating his pain: Under examination, a patient might state that he is too injured to lift a gallon of water, but under surveillance the patient is identified that same afternoon bench pressing like a maniac at his local gym — in investigative terms, we call this discrepancy, “acting outside of his stated limitations.”
Surveillance video becomes evidence that the patient is intending to defraud his medical provider in order to obtain the pharmaceuticals he’d become addicted to. In a best case scenario, the drug addicted patient is simply cut off from his supply, the insurance company refusing payment. In worse cases, the patient is prosecuted for filing a fraudulent medical claim and providing false information during exams.
Occasionally, the patient does time. If receiving probation instead, he is ordered to pay restitution to the big box insurers. The doctor, of course, skates with his medical practice, and bank account, intact.
I loved my grandfather. I loved the way he drove or walked slowly toward places that he cared about: A patient’s home, a restaurant once a week, the small rooms in the hospital he patrolled, and the inevitable small rooms of the soul that each of us moves toward when time beckons.
I loved that he cared about medicine. As such, I grew up caring about it, too, honoring those in the medical profession with a feeling of intimacy I have been hard pressed to explain. Today, though, there’s a doctor who could use a little prison stretch on the books, just a few months to get his head straight. I hope I can help put him there.
Right now, in the profession that sees me with my own black bag packed tightly with tools (the slim computer, pocket-sized DVR and tripod, rubber-banded batteries and digital voice recorder chronicling this doctor’s statement), I have a rare chance to make a difference.
Often enough, my investigations involve finding someone. Today, I am lucky to know right where he is.