Thread by @marshall_allen

1/ A woman discovered her ex husband was defrauding health insurance companies for millions. She tried bringing him to justice. It didn’t go as expected.

(This story is one of the wildest I’ve reported.)

Here’s what happened:

2/ Amy Lankford was suspicious when her ex, David Williams, who had a checkered history, gave their 3 children iPad Minis for Christmas in 2013. Where’d he get that kind of money?

Then, one day she noticed something on her son’s iPad…

3/ The device was still hooked up to her ex’s Apple account, and showed all the messages he was sending + receiving. The discovery made her heart pound. Unwittingly, she had uncovered a massive case of health care fraud.

4/ (Williams didn’t deny billing the insurers but defended his work in a letter to me, calling it an “unprecedented” opportunity to help people. A jury in U.S. District Court for the Northern District of Texas didn’t see it that way. He got sentenced to more than nine years.)

5/ When Lankford read her ex’s iPad messages, she saw that most were from people setting up workouts through his personal training business, Get Fit With Dave.

But that’s not all...

6/ Oddly, people were also providing their birthdates and the group number of their health insurance plans.

We’re talking industry giants:
-@Aetna
-@Cigna
-@UHC

Not something that you usually share w/ a personal trainer...

@Aetna @Cigna @UHC 7/ But, the people messaging with her ex husband were very pleased to hear that their health insurance would cover the costs of their fitness workouts.

That’s because: they usually don’t pay personal trainers.

So how did “Dr. Dave” pull it off? I’ll explain in a minute.

@Aetna @Cigna @UHC 8/ Lankford called her father, Jim Pratte, who has a finance MBA and already had strong feelings about his daughter’s ex.

(When I spoke to him, just mentioning “Dr. Dave” flushed his face and ratcheted up his Texas twang.)

@Aetna @Cigna @UHC 9/ Lankford and her dad were stunned at Dr. Dave’s audacity. They were sure the companies would quickly crackdown on what appeared to be a fraudulent scheme.

*Especially* because Williams had a criminal record.

@Aetna @Cigna @UHC 10/ When they were going through their divorce in 2006, Pratte had found a folder of fake invoices on his son-in-law and daughter’s computer.

In November 2008, Williams pleaded guilty in Tarrant County District Court to felony theft.

@Aetna @Cigna @UHC 11/ Two years later, their 11-year-old son showed up to school with bruising on his face. Investigators determined that Williams had hit the boy ~20 times. Williams pleaded guilty and spent 2 years behind bars.

@Aetna @Cigna @UHC 12/ The time behind bars didn’t go to waste. Williams revised the business plan for Get Fit With Dave, including arriving to the conclusion that he needed to get access to health insurance.

He asked a friend to remove the term “personal training” from his website.

@Aetna @Cigna @UHC 13/ To set his plan in motion, Williams needed what is essentially the key that unlocks access to health care dollars: a National Provider Identifier, or NPI number.

Without an NPI, providers can’t bill insurers for their services.

@Aetna @Cigna @UHC 14/ How’d he get around the fact that he wasn’t a doctor?

Williams discovered and exploited an astonishing loophole: Medicare doesn’t check NPI applications for accuracy (a process that would take less than a minute)

@Aetna @Cigna @UHC 15/ Criminal court records show Williams first applied for an NPI under his own name as far back as 2008. But it wasn’t until 2014 that Williams began to max out his scheme, even though now he wasn’t just unlicensed, he was a two-time felon.

Then, he got a SECOND NPI number.

@Aetna @Cigna @UHC 16/ He kept getting new NPIs. For every application, Williams also obtained a new employer identification number, used for tax purposes.

But he never hid who he was, using his real name, address and phone number on the applications.

Medicare gave him 20 NPIs!

@Aetna @Cigna @UHC 17/ Time to drum up business: “Now accepting most health insurance plans,” his Get Fit With Dave website announced.

He added a drop-down menu to his site, allowing potential clients to select their health insurance provider:

-Aetna
-Blue Cross Blue Shield
-United

@Aetna @Cigna @UHC 18/ He began building a team, soliciting trainers from the strength and conditioning department at Texas Christian University. He met with new recruits at local fast food joints or coffee shops to set them up. To the trainers, the business appeared legit.

@Aetna @Cigna @UHC 19/ He told clients their health plan would cover their fees, but didn’t tell them he was billing for medical services.

For example: one client received typical fitness training sessions, but records show her insurance was billed for treatment of “lumbago and sciatica.”

@Aetna @Cigna @UHC 20/ “Dr. Dave’s” business expanded to a dozen trainers and ~1,000 patients.

He bought a couple pick-up trucks, a new Harley and a fancy house.

The checks from insurance companies kept rolling in. Look at this whopper from United!

Business was good.

@Aetna @Cigna @UHC 21/ With all their evidence, Amy Lankford and her father thought that they had an open-and-shut case.

It wasn’t the case:

@Aetna @Cigna @UHC 22/
-an @Aetna customer service rep told them non-members couldn’t report any criminal activity. Lankford and Pratte never heard back from them.

-a @Cigna investigator called asking for more info, which they shared. Then crickets.

-calls to @UHC were similarly ineffective.

@Aetna @Cigna @UHC 23/

Even after the insurers caught him, Dr. Dave continued his scheme. Mostly, they asked him to pay them back. He just reached into his bag of NPIs to keep billing them. They kept paying!

In 2017, @UHC finally contacted the FBI.

@Aetna @Cigna @UHC 24/ In all, from the time Lankford found the texts, it took authorities *3 years* to finally stop “Dr. Dave.”

In total, he ran the scheme for more than 4 years, billing top insurance companies like @UHC, @Aetna + @Cigna for $25 million and reaping about $4 million in cash.

@Aetna @Cigna @UHC 25/ That’s a small piece of the overall tally of health care fraud. The truth is no one keeps track of how much is lost to health care fraud. Experts told me it could be 10% of what we spend. Those losses get passed on to all of us.

@Aetna @Cigna @UHC 26/ The insurance companies wouldn’t do an interview with me about the Williams case. They said in emails that they care about fraud and take the problem seriously.

@Aetna @Cigna @UHC 27/ Medicare officials declined to be interviewed about Williams. But in a statement, they acknowledged that the agency doesn’t verify whether an NPI applicant is a medical provider or has a criminal history.

@Aetna @Cigna @UHC 28/ Medicare warns NPI applicants that submitting false information could lead to a $250,000 fine and five years in prison. But since they started issuing NPIs in 2006, officials said they could not identify *anyone* who had been sanctioned.

@Aetna @Cigna @UHC 29/ So, for those bent on fraud, the first step is easy:

The online approval for an NPI takes mere minutes.

@Aetna @Cigna @UHC 30/ Thanks for reading all this.

For more astonishing details, check out the full story, co-published with @voxdotcom, on @ProPublica here: propublica.org/article/health…

@Aetna @Cigna @UHC @voxdotcom @propublica 31/ Fixes exist to the problems identified in this story. See here for details: propublica.org/article/what-c…

@Aetna @Cigna @UHC @voxdotcom @propublica 32/ And if you’re familiar with the world of health insurance and employer-sponsored benefits, you can share a tip with me here: propublica.org/getinvolved/th…

@Aetna @Cigna @UHC @voxdotcom @propublica 33/ Also, @ProPublica has a setup to notify you of our biggest investigations, no insurance coverage necessary: propub.li/2LdoRh6

@Aetna @Cigna @UHC @voxdotcom @propublica 34/ If you have read this far, then I am seriously impressed. Thank you!