John Mininno — Photo/João Canziani
❝ John Mininno slaps two pieces of paper onto an overhead projector. “Look at this,” he says. “You see how one form is a photocopy of the other—with just the date changed? It’s exactly the same paper!” The printouts are mere insurance forms, but Mininno is genuinely pissed off about them. “They’re allowed to bill for that procedure again six months after they first provide it. That date is six months to the day!”
Not everyone can get this worked up about insurance forms. But to Mininno, these are a combination of smoking gun and a slap in the face. Together they clearly show that someone is ripping off Medicare. But perhaps what’s worse is that someone is being really lazy about it.
❝ If Willie Sutton had to choose a criminal career today, he’d be ripping off Medicare too. As the bank robber supposedly said: That’s where the money is. The program spends more than $600 billion a year on health care for 54 million people, most of them seniors. It is a massive pool of underguarded funds ripe for skimming. By the government’s own accounting, fraudsters scammed $60 billion from Medicare in 2014, and the losses are growing. Since 2007 more than 2,300 health care providers have been charged with fleecing Medicare, and more than 1,800 defendants have been convicted of felony offenses, ranging from claiming phantom services to performing unnecessary surgeries.
Scams are run so often, by so many people, that dedicated government investigators can’t keep up: In 2014 prosecutions initiated by the government led to a mere 31 settlements yielding $88 million in fines. Luckily, there is another defense against Medicare fraud: whistle-blower lawsuits. Under the federal government’s false claims statute, any insider can sue a company that’s providing fraudulent services, on the government’s behalf. If the whistle-blower lawyers are successful, the plaintiffs collect 15 to 30 percent of the settlement as a bounty. In 2014 there were 469 of these health care fraud settlements—many involving huge pharmaceutical corporations and hospital networks—resulting in $2.2 billion in fines.
❝ The problem is that even with this financial incentive, whistle-blowers can be skittish about coming forward and often are ill-prepared to present solid evidence…Professional whistle-blower lawyers are much better at arguing a convincing case. But lawyers aren’t always the best investigators. Sometimes finding an insider requires a nose for mischief, a gift for persuasion, and the technical chops to identify nonobvious patterns in impenetrable thickets of diagnostic codes and billing data. Sometimes it takes a bounty hunter. Someone like John Mininno…
RTFA. Some of it is hilarious. Some is about how interesting and useful skilled data mining can be. All of it is about crime. The most meaningful thing about that crime is that the people who pat themselves on the back for providing healthcare to Americans are host to one of the largest class of criminals in America. These are doctors and nurses, hospital administrators, insurance companies and local medical clinics. They provide healthcare for every illness from diabetes to bipolar disorder. They steal from taxpayers.
On a personal note, just one more example of why I’d be working at extending my grounding in computational analysis – if I were starting out working for a living as a geek, today. From scientific research to forensic data mining, the craft is fascinating.