The Impact of Insurance Fraud on NJ’s Citizens

>>HI, I'M GERRY LIPKIN AT VALLEY NATIONAL BANK WE BELIEVE CONSUMERS NEED HELP UNDERSTANDING THE COMPLEX BANKING AND FINANCIAL ISSUES AFFECTING THEIR LIVES THAT'S WHY WE'RE PROUD TO SUPPORT THE PROGRAMMING PRODUCED BY THE CAUCUS EDUCATIONAL CORPORATION >>HOW INSURANCE FRAUD COSTS YOU NEXT ON CAUCUS NEW JERSEY FUNDING FOR THIS EDITION OF CAUCUS NEW JERSEY HAS BEEN PROVIDED BY VALLEY NATIONAL BANK FELICIAN UNIVERSITY A TWENTY FIRST CENTURY EDUCATION, BASED ON TIMELESS VALUES NEW JERSEY RESOURCES THE ROBERT WOOD JOHNSON FOUNDATION THE NEW JERSEY STATE NURSES ASSOCIATION AND THE INSTITUTE FOR NURSES ADVOCATING, POSITIONING, EDUCATING NJ'S RNS.

NJ BEST, NEW JERSEY'S 529 COLLEGE SAVINGS PLAN TURNING A DREAM INTO A DEGREE AND BY CHOOSE NEW JERSEY OUR MISSION IS ATTRACTING COMPANIES TO THE GARDEN STATE PROMOTIONAL SUPPORT PROVIDED BY NJ BIZ, ALL BUSINESS ALL NEW JERSEY AND BY THE NEW JERSEY CHAMBER OF COMMERCE, THE STATEWIDE VOICE OF BUSINESS IN NEW JERSEY [MUSIC PLAYING] [MUSIC PLAYING] CLOSED CAPTIONING PROVIDED BY – – – -=ACIEM STUDIOS=- – – – – – -WWW.

ACIEMSTUDIOS.

COM- – – >>WELCOME TO CAUCUS NEW JERSEY I'M STEVE ADUBATO, YOU KNOW INSURANCE FRAUD IS NOT A VICTIMLESS CRIME.

IT COSTS NEW JERSEY RESIDENTS 1,300 DOLLARS PER YEAR, AND HAS A VERY NEGATIVE IMPACT ON THE STATE'S ECONOMY.

HERE IN THE STUDIO TO DISCUSS WHAT INSURANCE FRAUD IS, AND WHAT IT MEANS TO YOU, WE'RE JOINED BY WARD SANDERS PRESIDENT OF THE NEW JERSEY ASSOCIATION OF HEALTH PLANS PHYLLIS SALOWE-KAYE IS EXECUTIVE DIRECTOR OF NEW JERSEY CITIZEN ACTION TERRI DIGIORGIO SUPERVISORY SPECIAL AGENT AT THE NATIONAL INSURANCE CRIME BUREAU, AND FINALLY CHRISTOPHER IU ACTING INSURANCE FRAUD PROSECUTOR IN THE NEW JERSEY OFFICE OF THE ATTORNEY GENERAL I WANT TO THANK ALL OF YOU FOR JOINING US TO TALK ABOUT INSURANCE FRAUD, CHRIS, WE'VE BEEN HAVING THIS CONVERSATION FOR THE LAST YEAR AND A HALF OR SO, PUT THIS IN CONTEXT ALSO A SERIES OF PSA'S RUNNING ON PUBLIC TELEVISION RIGHT NOW ABOUT INSURANCE FRAUD WHAT IS THE ISSUE? AND WHY DOES IT MATTER? >>WELL THANK YOU SO MUCH FOR HAVING US HERE TODAY STEVE I THINK IT'S A VERY IMPORTANT ISSUE, INSURANCE FRAUD MANY PEOPLE DON'T SEE IT AS A "CRIME" YOU HAVE YOUR ORDINARY CITIZENS WHO WOULD NORMALLY NOT GO OUT AND ROB A BANK, OR STEAL FROM OTHER INDIVIDUALS, BUT WE HAVE COMMITTING INSURANCE FRAUD WHETHER IT'S ON AN APPLICATION THAT THEY'RE LYING ON, WHETHER THEY'RE SUBMITTING FOR CLAIMS OR BENEFITS THAT THEY ACTUALLY DIDN'T RECEIVE.

SO IT AFFECTS EVERYBODY AS A WHOLE.

NOT JUST THE INSURANCE INDUSTRY, BUT INDIVIDUALS >>BUT WHY INSU.

SEE WE'RE TALKING ABOUT INSURANCE FRAUD, IS THAT DIFFERENT FROM LYING ON A BANK APPLICATION ABOUT A LOAN? I JUST WANT TO UNDERSTAND, IS INSURANCE FRAUD SOME UNIQUE KIND OF FRAUD? >>I DON'T THINK IT'S NECESSARILY UNIQUE.

FRAUD IS FRAUD.

PEOPLE ARE MISREPRESENTING THEMSELVES OR MISREPRESENTING THEIR ASSETS, OR MISREPRESENTING WHATEVER CLAIM THEY HAVE BUT SPECIFICALLY, INSURANCE FRAUD, IT AFFECTS ALL OF US EACH INDIVIDUAL, SAY WE HAVE WORKER'S COMPENSATION FRAUD IF YOUR BOSS IS NOT PAYING UP THE WORKER'S COMPENSATION FRAUD, YOU MIGHT NOT BE ADEQUATELY COVERED IF YOU GET HURT AT WORK.

SAY THERE'S LIFE INSURANCE FRAUD, IF SOMEONE COMES TO YOU AND SAID "HEY, WE CAN GIVE YOU A FREE POLICY FOR A YEAR" USUALLY THEY ONLY PAY PART OF THE PREMIUM AND LET IT LAPSE SO MAYBE YOU WON'T BE COVERED IT AFFECTS INDIVIDUAL PEOPLE NOT JUST CORPORATIONS >>JUST JUMP IN HERE WARD, AND I'LL COME BACK TO YOU FELLOWS, WHAT'S THE DIFFERENCE BETWEEN FRAUD, WASTE, AND ABUSE WHEN WE'RE TALKING ABOUT INSURANCE? >>SURE.

THE THREE CONCEPTS ARE OFTEN TALKED ABOUT TOGETHER BUT THE WASTE AND ABUSE ARE SORT OF THE COUSINS OF FRAUD, I THINK OF FRAUD AS SOMETHING WHERE THERE'S A KNOWING AND WILLFUL VIOLATION >>INTENT? >>INTENT, SO IN LAW WE CALL IT MENS REA, BUT IT'S, YES, YOU HAVE TO HAVE AN INTENTION AND AN UNDERSTANDING OF WHAT YOU'RE WHAT YOU'RE DOING.

WASTE AND ABUSE CAN BE A INAPPROPRIATE USE OF RESOURCES, IT'S A HAVING TESTS THAT DON'T REALLY MATTER, OR DON'T.

>>THAT'S NOT WHAT WE'RE TALKING ABOUT? >>THAT'S WASTE AND ABUSE BUT THERE'S NO INTENT HERE FRAUD IS MATERIALLY DIFFERENT BECAUSE IT'S THE INTENT THE PERSON KNOWS WHAT THEY'RE DOING, AND INTENDS TO DO IT THAT'S WHAT WE'RE TALKING ABOUT >>YOU FEEL IT'S THE MOST COMMON YEAH YOU'RE MAKING, WHAT? >>WELL I GUESS MY CONCERN IS THAT WE SEEM TO ONLY BE TALKING ABOUT FRAUD BEING COMMITTED BY AN INDIVIDUAL OR A CONSUMER >>CONSUMERS, YEAH >>AND I, WE SEE A LOT OF FRAUD BEING COMMITTED BY THE PROVIDERS, WHETHER IT'S OF HEALTHCARE, OR AUTO INSURANCE IT'S NOT JUST A ONE WAY STREET CERTAINLY THERE ARE INDIVIDUALS THAT HAVE DEFRAUDED THE SYSTEM BUT THERE'S ALSO MANY INSTANCES WHETHER IT'S AUTOBODY SHOPS WHEN YOU TAKE YOUR CAR FOR A REPAIR, AND THEY BUILD UP THE BILL, OR PROVIDERS OF INSURANCE >>YEAH >>LIKE HOSPITALS THAT ADD WHEN YOU CHECK YOUR BILL, YOU >>SURE >>FIND OUT THAT THERE'S LOTS OF THINGS ON THERE THAT YOU NEVER CONTRACTED FOR, OR KNEW THAT YOU HAD >>PHYLLIS.

>>SO I'M CONCERNED ABOUT THAT WE'RE JUST TALKING ABOUT FRAUD BY AN INDIVIDUAL >>SORRY FOR INTERRUPTING PHYLLIS, PHYLLIS MAKES AN INTERESTING POINT I'VE OFTEN THOUGHT ABOUT THIS FRAUD THING, AND I SAY TO MYSELVES, FIRST OF ALL, MYSELF FIRST OF ALL, HOW DOES IT START? AND I GUESS EVERY CASE IS DIFFERENT, BUT IN ORDER TO SUCCESSFULLY, AND I USE THAT WORD ADVISEDLY, SUCCESSFULLY EXECUTE INSURANCE FRAUD, A CONSUMER CANNOT DO IT ALONE? A CONSUMER WOULD NEED THE COLLABORATION OF OTHERS AM I WRONG ABOUT THAT? >>NO YOU'RE RIGHT ABOUT THAT THE COLLABORATION, THAT'S WHERE YOU WILL BRING IN THE CRIMINAL RUNNERS, IN NEW JERSEY WE HAVE A CRIMINAL RUNNER STATUTE >>EXPLAIN THAT TO US >>A RUNNER IS A PERSON THAT FOR ANY KIND OF FINANCIAL BENEFIT, REFERS A PATIENT TO A MEDICAL PROVIDER, OR AN ATTORNEY, GETS HIS FEE, AND ALSO PAYS.

>>THE RUNNER GETS THE FEE? >>YES >>LIKE, OKAY GO AHEAD >>THE RUNNER GETS A FEE FROM THE DOCTOR, OR THE ATTORNEY, AND WE'RE TALKING ABOUT UNSCRUPULOUS DOCTORS AND ATTORNEYS, WE'RE NOT TALKING ABOUT THE AVERAGE DOCTOR, WHAT WE DO IS MEDICAL PROVIDER FRAUD, THAT'S WHAT WE CONCENTRATE ON IN EDISON, NEW JERSEY.

OKAY, GETTING BACK TO THE RUNNER, THEY RECRUIT PEOPLE, AND UNFORTUNATELY THEY GO INTO LOW INCOME AREAS URBAN AREAS, WHERE PEOPLE FEEL OKAY, I CAN JUMP ON THIS I CAN MAKE A COUPLE OF BUCKS ON THIS >>WHAT'S "THIS"? EXPLAIN TO US AND THIS WHERE GET TORN IN >>OKAY >>PUBLIC TELEVISION, I KNOW WE NEED TO TALK ABOUT SPECIFIC INSTANCES, BUT SOMEONE WOULD SAY, "WELL YOU JUST TAUGHT PEOPLE HOW TO DO THIS" BUT THE FACT IS, WE NEED TO HELP PEOPLE UNDERSTAND WHAT EXACTLY YOU'RE TALKING ABOUT.

COULD YOU GIVE US A CONCRETE EXAMPLE? >>YES, I MEAN, WELL I CAN GIVE YOU A CONCRETE EXAMPLE I'M NOT GONNA MENTION DOCTOR'S NAMES >>DON'T NEED THAT WE DON'T NEED NAMES OF ANYONE OR ANYTHING, BUT CALL IT WHAT IT IS, AND EXPLAIN IT >>IT'S CALLED INSURANCE FRAUD IT'S CALLED STAGED ACCIDENT SCAMS, THAT RELATE TO.

>>STAGED ACCIDENT? >>STAGED ACCIDENTS, YEAH THERE ARE PEOPLE THAT WILL ACTUALLY STAGE AN ACCIDENT HIT EACH OTHER, OR THEY WILL SAY THAT THEY WERE IN A STAGED ACCIDENT, THAT THEY WERE IN AN ACCIDENT, AND THEN THEY WILL.

>>IN THEIR CARS? >>IN THEIR CARS, YES >>AND THEN WHAT? >>THEY ACT LIKE THEY'RE HURT OR THEY MAYBE THEY ARE HURT BUT THEY STAGED IT, THEY CAUSED IT, SOMETIMES THEY HIT INNOCENT PEOPLE, SOME, AND MANY TIMES IT'S TWO PEOPLE THAT ARE CORROBORATING, AND THEY HIT EACH OTHER >>AND THEN WHAT DO THEY DO? THEY MAKE THE CLAIM TO THE INSURANCE COMPANY? >>THEY MAKE THE CLAIMS TO THE INSURANCE COMPANY >>BUT ARE DOCTORS INVOLVED TOO SOMETIMES? >>YES.

YES >>S.

CHRIS, SO THIS ISN'T JUST.

? >>RIGHT >>PHYLLIS MADE A GOOD POINT THIS ISN'T CONSUMERS DRIVING THIS BY THEMSELVES >>IT'S NOT, IT'S CONSUMERS IT'S PROVIDERS, IT'S LIKE WE TALKED ABOUT IT, IT'S EVERYBODY, SO AS TERRI WAS TALKING ABOUT STAGED ACCIDENTS A LOT OF TIMES WE SEE THESE RUNNERS OUT THERE INDIVIDUALS WHO SHOW UP AT ACCIDENT SCENES, OR GO AND GET THE POLICE REPORTS AND DETERMINE THAT, HEY SOMEBODY'S BEEN IN AN ACCIDENT WE'LL GIVE MONEY TO, OR ENCOURAGE AN INDIVIDUAL TO SEE A CERTAIN DOCTOR THAT THEY'RE GETTING PAID BY >>DO THEY KNOW SOMETHING ABOUT THAT DOCTOR? >>USUALLY THEY'RE EMPLOYED BY THE DOCTOR IN SOME SHAPE OR FORM, TO COME GET MEDICAL SERVICES FROM THIS DOCTOR SO THE DOCTOR CAN BILL THE INSURANCE COMPANY.

SO A LOT OF TIMES IT IS LEGITIMATE PEOPLE ARE LEGITIMATELY HURT WE'RE NOT TAKING THAT AWAY FROM INDIVIDUALS, BUT OTHER TIMES, THE DOCTORS WILL MAKE YOU COME BACK AND TREAT TWO OR THREE OR FOUR TIMES TO MAINTAIN THE BILLING, WHETHER IT'S PRIVATE INSURANCE OR WHETHER IT'S MEDICAID >>BUT LET'S, LET ME PLAY DEVIL'S ADVOCATE.

WHAT WOULD YOU SAY TO SOMEONE WHO SAYS "LOOK, THE SYSTEM, IT'S TOO EXPENSIVE, INSURANCE IS TOO EXPENSIVE, THIS IS AN OPPORTUNITY FOR ME TO RECOUP SOMETHING BACK, I'VE BEEN PRESENTED WITH THIS OPPORTUNITY WHO AM I HURTING?" COME ON FELLOWS >>THEY'RE HURTING EVERYBODY >>EXPLAIN THAT >>BECAUSE THE COST GETS PASSED ON AND THEN.

>>HOW? >>IN OUR PREMIUMS, JUST THE SAME WAY IF YOU, INSURANCE >>IT GETS PUT IN THE BILL? >>COMPAN.

WELL, THE COST OF YOUR PREMIUM, WHETHER IN HEALTHCARE OR AUTO RAISES BECAUSE SOMEBODY HAS TO COVER THE FRAUDS WHEN THEY'RE DISCOVERED, IF YOU GO TO MACY'S AND BUY A PAIR OF PANTS YOU'RE PAYING EXTRA FOR THOSE PAIR OF PANTS TO PAY FOR PEOPLE WHO SHOPLIFT AT MACY'S I MEAN, FRAUD IS BUILT INTO THE CONSUMER'S COST OF, WHETHER IT'S A POLICY, OR AN ITEM THAT THEY PURCHASE.

INSURANCE >>SO ARE CONSUMERS, SO EVERYONE >>COMPANIES KNOW THEY'RE GETTING SCAMMED, SO THEY THEY COVER THAT, WHEN THEY CHARGE YOU YOUR PREMIUM >>SO TO CALL THIS A QUOTE "VICTIMLESS CRIME" IS ABSOLUTELY WRONG? >>ABSOLUTELY WRONG, AND PHYLLIS IS RIGHT TOO, THAT THE I THINK THAT THERE IS CONSUMER FRAUD IN HEALTHCARE, YOU SEE SOME IDENTIFY FRAUD, WHERE SOMEONE ISN'T REALLY INSURED BUT THEY'LL HAVE A CARD THAT THEY'VE EITHER STOLEN OR THAT THEY'LL USE FROM A RELATIVE, AND PURPORT THAT THEY'RE SOMEONE THAT THEY'RE NOT, TO GET SERVICES, BUT THAT'S A SMALL PIECE OF THE FRAUD PIE, REALLY MOST OF THE PROVIDER FRAUD IS ON THE PROVIDER SIDE.

SOMETIMES IN CAHOOTS WITH CONSUMERS BUT OFTEN TIMES NOT, IT'S IT'S THINGS LIKE BILLING FOR SERVICES THAT YOU DIDN'T PROVIDE, IT'S UPCODING SO THE LANG.

>>UPCODING? >>TECHNICAL TERM, BUT IT'S THE BILLING, IT'S THE, SO THE LANGUAGE THAT CARRIERS INSURANCE COMPANIES AND PROVIDERS SPEAK TO MAKE SURE THAT PAYMENT IS MADE, THEY WILL BILL FOR A CODE THAT HAS A HIGHER REIMBURSEMENT THAN THE >>OH BOY >>SERVICE THAT THEY REALLY PROVIDED, AGAIN, THE CONSUMER MAY NOT EVEN KNOW, BUT THE BUT THE PROVIDER IS AWARE OF IT THE CONSUMER ROLE HERE, BY THE WAY, AND THE CONSUMERS CAN HAVE A ROLE IN HELPING TO SOLVE THIS I THINK OF HOMELAND SECURITY IF YOU SEE IT, SAY SOMETHING >>WHO DO YOU SAY.

? HOLD ON BACK UP, WHO DO YOU SAY IT TO CHRIS? I'LL COME BACK TO YOU FELLOWS, WHO DO YOU SAY IT TO? AND BY THE WAY, LET'S PUT UP THE INFORMATION RIGHT NOW WHO DO YOU SAY IT TO? AND WHAT DO YOU SAY? >>I SAY YOU CAN CALL MY OFFICE WE HAVE A FRAUD HOTLINE 1-877-55F-RAUD, OR YOU CAN.

>>SAY THAT AGAIN? >>1-877-55F-RAUD, OR YOU CAN GO TO OUR WEBSITE, NEW JERSEY.

WWW.

NJINSURANCEFRAUD.

ORG >>WHAT HAPPENS WHEN YOU GO THERE? >>WHEN YOU GO TO OUR.

>>WHAT HAPPENS WHEN YOU CALL? >>WHEN YOU GO TO OUR WEBSITE WHEN YOU CALL, WE HAVE A HOTLINE THAT'S MANNED, I THINK 8 TO 5 NORMAL, A LITTLE BIT NORMAL BUSINESS HOURS, AND WE HAVE CIVIL INVESTIGATORS WHO ARE ABLE TO TALK YOU THROUGH THE SITUATION DETERMINE WHETHER IT IS ACTUAL INSURANCE FRAUD OR SOME OTHER GRIEVANCE THAT MAYBE WE CAN HELP DIRECT YOU TO SOME PLACE ELSE, AND WE HAVE INTAKE FORMS, WHERE WE CAN HAVE CRIMINAL INVESTIGATORS DELVE A LITTLE BIT DEEPER INTO, OR CONTACTING THE INSURANCE AGENCIES TO SPEAK WITH THEM TO SEE IF THEY'RE SEEING SOMETHING SIMILAR >>WHAT ABOUT IF SOMEONE'S AFRAID, "HEY LISTEN, I DON'T WANT.

I KNOW, I'M PRETTY SURE SOMETHING IS HAPPENING, I DON'T KNOW EXACTLY WHAT IT IS, BUT I'M NOT SURE I WANT TO GET THAT INVOLVED, OR HAVE SOMEONE KNOW THAT I WAS THE ONE"? >>SO ON OUR WEBSITE, YOU CAN ALSO FILL OUT DOCUMENTS OR, I GUESS, APPLIC.

NOT NECESSARILY APPLICATIONS BUT DOCUMENTS THAT DETAIL WHAT THE FRAUD IS, WHAT YOU THINK IT IS, AND YOU DON'T NECESSARILY HAVE TO LEAVE YOUR CONTACT INFORMATION, JUST TO GIVE US A LEAD, CARRIER INFORMATION, OR PERSONAL INFORMATION OF THE INDIVIDUAL YOU THINK IS COMMITTING FRAUD SO WE CAN TAKE A FURTHER DEEPER DIVE INTO IT >>YOU WANT TO JUMP BACK IN PHYLLIS? >>I WAS JUST GONNA SAY YESTERDAY, STAR LEDGER, FRONT PAGE, 67 MILLION DOLLARS MEDICAID FRAUD BY AN AMBULANCE COMPANY THAT WAS TAKING SENIORS TO PLACES THAT WEREN'T COVERED SHOWING UP LATE, NOT SHOWING UP AT ALL, THAT'S FRAUD >>THAT'S FRAUD? >>THEY GOT PAID, THEY GOT PAID THROUGH THE STATE OF NEW JERSEY IF I'M NOT MISTAKEN >>SO WHAT'S INTERESTING ABOUT THIS IS IT HAPPENS IN, ON ALL LEVELS, YOU KNOW WHAT'S INTERESTING? THE LAWS THEMSELVES, I'M CURIOUS ABOUT THIS, WHAT IS THE LAW ABOUT INSURANCE FRAUD? I MEAN I KNOW THERE ARE MULTIPLE LAWS BUT THERE ARE PENALTIES HERE, BECAUSE THE PUBLIC SERVICE ANNOUNCEMENT THAT THAT WE HAVE AIRING ON SOME OF OUR PROGRAMS ACTUALLY TALKS ABOUT THE PENALTIES WHAT ARE THE PENALTIES? CAN WE TALK ABOUT THIS? >>YEAH SO ON THE PENALTY SIDE WE HAVE HEALTHCARE FRAUD WHICH IS OFTEN DONE BY MEDICAL PROVIDERS, DOCTORS CHIROPRACTORS, IT'S A 2ND DEGREE CRIME, YOU CAN FACE FIVE TO TEN YEARS IN JAIL AND THE FINE IS UP TO 150,000 DOLLARS.

DO THE DOCTORS GET FINED THAT MUCH? USUALLY NOT BUT USUALLY THERE'S SOME AMOUNT OF RESTITUTION, OR THERE'S SOME MONETARY FINE ATTACHED TO IT >>QUICK, BEFORE WE GO TO THIS BREAK, WHAT'S THE MESSAGE YOU WANT TO LEAVE THE CONSUMERS AS WE GO AFTER THIS BREAK RIGHT NOW, WHO SAY "LISTEN, I HEAR WHAT YOU'RE SAYING, I DIDN'T REALIZE IT WAS THAT EXTENSIVE, BUT YOU KNOW WHAT? I'M JUST ONE PERSON"? >>IT IS EXTENSIVE, AND THE PROBLEM IS IS THE ENTITLEMENT FACTOR, BUT THE GENERAL PUBLIC UNFORTUNATELY, HAS AN ENTITLEMENT FEELING, THAT I'VE BEEN PAYING MY PREMIUMS ALL THIS YEAR, ALL THESE YEARS SO I'M ENTITLED TO GET PAID AT SOME POINT, EVEN IF.

>>I'M GONNA GET MINE? >>EVEN IF I DON'T HAVE A LEGITIMATE CLAIM >>CAN YOU UNDERSTAND THAT PSYCHOLOGY? >>I CAN UNDERSTAND IT BUT I DON'T CONDONE IT >>IT'S A BIG DIFFERENCE? >>YEAH >>UNDERSTANDING SOMEONE'S FRUSTRATING, FRUSTRATED BUT CONDONING AN ILLEGAL ACT THAT HURTS OTHER PEOPLE TWO DIFFERENT THINGS? >>MM HMM >>STAY ON THAT POINT WE'LL COME RIGHT BACK RIGHT AFTER THIS TALKING ABOUT INSURANCE FRAUD IN NEW JERSEY, AND WHAT IT MEANS TO YOU, WE'LL BE RIGHT BACK >>TO SEE MORE CAUCUS NEW JERSEY WITH STEVE ADUBATO PROGRAMS VISIT US ONLINE AT WWW.

STEVEADUBATO.

ORG IF YOU WOULD LIKE TO EXPRESS AN OPINION, EMAIL US AT INFO@CAUCUSNJ.

ORG FIND US ON FACEBOOK AT FACEBOOK.

COM/STEVEADUBATOPHD AND FOLLOW US ON TWITTER AT @STEVEADUBATO >>TALKING INSURANCE FRAUD EVERYONE WATCHING RIGHT NOW FOLLOW THE WEBSITES AND THE TELEPHONE NUMBERS WE PUT UP RIGHT NOW, YOU WERE JUST SAYING DURING THE QUICK BREAK, RIGHT NOW, THERE'S A CASE INVOLVING THE US ATTORNEY'S OFFICE YOU'RE PROSECUTING RIGHT NOW TELL US ABOUT THAT >>THERE WAS A CASE THAT WAS PROSECUTED, I'M NOT GONNA MENTION THE NAME OF THE DOCTOR >>GO AHEAD >>BUT HE WAS OUT OF LITTLE FALLS, NEW JERSEY, YOU CAN LOOK IT UP AND I'M SURE YOU COULD EASILY FIND IT, THE DOCTOR WAS BASICALLY FALSIFYING DOCUMENTATION SO THAT HE COULD BILL THE INSURANCE COMPANIES SO WHAT HE WAS DOING, HE WAS NOT SEEING THE PATIENT, HE WOULD BILL AS IF HE WAS SEEING THE PATIENT, HE WOULD FALSIFY VITALS, HE'S FALSIFY BLOOD PRESSURE READINGS, PRESCRIPTION MEDICINES, ANY TYPE OF COMPLAINTS, THIS WENT ON FOR I BELIEVE BETWEEN 2008 AND 2013 HE FINALLY WAS INDICTED AND HE PLED GUILTY, AND HE THOUGHT HE WAS GOING TO RECEIVE PROBATION UNFORTUNATELY, THAT'S A LOT OF TIMES WHAT HAPPENS, BUT PRIOR TO HIM BEING SENTENCED, THE JUDGE, EXCUSE ME, THE JUDGE WAS MADE AWARE OF A WORKER'S COMP CLAIM THAT HE HAD FILED A COUPLE OF DAYS PRIOR TO THAT THAT CAME TO MY DESK.

I FOUND THE CLAIM WITH HIS NAME ON IT AS A WORKER'S COMP CLAIM CLAIMANTS, NOT A DOCTOR, NOT A MEDICAL PROVIDER, FILED A CLAIM THAT HE WAS, HIS DISTRESS DUE TO FILING THE DOCUMENTATION THAT HE WAS REQUIRED TO FILE GAVE HIM SO MUCH STRESS THAT HE COULDN'T DO HIS JOB ANYMORE >>WHAT HAPPENED? >>HE NEVER TOLD THE INSURANCE COMPANY HE HAD BEEN INDICTED WHAT HAPPENED IS HE RECEIVED THREE YEARS INSTEAD OF THREE INSTEAD OF PROBATION.

>>THREE YEARS IN? >>THREE YEARS IN PRISON 280,000 DOLLARS IN RESTITUTION AND ANOTHER THREE YEARS SUPERVISED RELEASE >>DID HE LOSE IS LICENSE? >>YES >>THIS IS NO JOKE AND PEOPLE WHO THINK, QUOTE I OFTEN HEAR PEOPLE SAY THIS AGAIN, MY JOB IS TO PLAY DEVIL'S ADVOCATE, WITH ALL THE THINGS GOING ON IN THE WORLD WE'RE TRYING TO DEAL WITH WITH THREATS FROM FOREIGN AGENTS, IF YOU WILL, AND AND TERRORISM, AS WELL AS STRIFE IN OUR OWN COUNTRY AND ALL KINDS OF DIFFICULT SITUATIONS, WE'RE DOING THIS IN THE SUMMER OF 2016, AND YOU WANT TO TALK ABOUT INSURANCE FRAUD? COME ON! HOW BIG A DEAL COULD THIS REALLY BE? WARD, GO >>I.

>>CAUSE YOU KNOW PEOPLE ARE SAYING THAT RIGHT NOW >>YEAH, I'LL GIVE YOU TWO CONCRETE EXAMPLES WHERE I THINK THIS IS REALLY MEANINGFUL TO FOLKS.

NUMBER ONE, YOU LOOK AT A PHARMACY THAT'S TURNED INTO A PILL MILL, IT'S SELLING >>WHAT? EXPLAIN THAT >>SELLING OPIOIDS, SELLING OPIOIDS INAPPROPRIATELY YOU KNOW THERE'S MASSIVE AMOUNTS OF OPIOIDS GOING.

>>OPIOIDS, EXPLAIN OPIOIDS ARE TANTAMOUNT TO HEROIN IN A PILL? >>AND IT'S A KILLER, IT'S A PAIN MEDICATION THAT CAN BE USED APPROPRIATELY, BUT IT IS OVERUSED, THERE'S A STREET VALUE TO IT, AND THEY'RE HAVING CREATED THESE PHARMACIES THAT TURN INTO PILL MILLS THAT ARE JUST PUMPING OUT OPIOIDS THAT'S A KILLER >>WHAT DOES THAT HAVE TO DO WITH INSURANCE FRAUD? >>THERE'S, THEY'LL BILL FOR THE INSURANCE, THE REASON THEY'RE DOING IT IS TO MAKE MONEY SO THEY'LL BILL THE INSURANCE COMPANY FOR THE SERVICES PROVIDED, BUT THEY'RE NOT ACTUALLY, YOU KNOW, THE MONEY'S JUST GOING OUT THE DOOR >>AND KEEPING THOSE PATIENTS COMING, AND BILLING THE INSURANCE COMPANIES, IT VICTIMIZES THE PATIENT, IN A SENSE, THEY BECOME DRUG ADDICTS AND ONCE THEY CAN'T GET THE PILLS ANYMORE, THAN THEY LOOK FOR HEROIN >>YOU KNOW, AND WE'RE TALKING ABOUT THE INDIVIDUAL HUMAN IMPACT, CHRIS, WE TALKED ABOUT 1,300 DOLLARS PER PERSON IN THE STATE, WHAT ABOUT THE ECONOMIC IMPACT TO THE STATE? >>RIGHT >>SO THE STATE DOES FUND THE MEDICAID TO INDIVIDUALS WHO APPLY FOR IT, OR ARE ABLE TO GET IT.

SO WHEN YOU HAVE INDIV.

WHEN YOU HAVE I GUESS, PROVIDERS OR INDIVIDUALS BILKING THE MEDICAID SYSTEM, IT'S COSTING THE STATE MONEY, IT'S COSTING OUR ECONOMY MONEY, SO THERE'S NOT ENOUGH MONEY TO GO AROUND WHETHER TO SERVICE THE INDIVIDUALS WHO ACTUALLY NEED HELP >>THE PEOPLE WHO REALLY NEED THAT HELP? >>YEAH, THAT ACTUALLY NEED THAT HELP, AND IT'S COSTING THE TAXPAYERS MONEY BECAUSE WE HAVE TO PUT MORE MONEY INTO THE SYSTEM TO PAY FOR ALL OF THESE FRAUDULENT ACTIVITIES >>PHYLLIS, TALK ABOUT THE ROLE THAT YOUR ORGANIZATION CAUSE YOUR ORGANIZATION WE'VE TALKED TO YOUR ORGANIZATION FOR YEARS YOU ADVOCATE FOR CONSUMERS? YOU PROTECT CONSUMERS YOU HELP CONSUMERS WHAT THE HECK IS THE MESSAGE ON INSURANCE FRAUD? >>WE TRY AND EDUCATE CONSUMERS SO A CONSUMER NEEDS TO BE AWARE WHEN THEY GO TO THE HOSPITAL AND THEY COME HOME, THEY HAVE TO READ THOSE BILLS, THEY HAVE TO READ THE EOB'S, THEY HAVE TO SEE.

>>EOB'S? >>THE STATE.

>>EXPLANATION OF BENEFITS >>EXPLANATION OF BENEFITS >>GOOD, THANK YOU >>THEY HAVE TO SEE WHAT THE HOSPITAL HAS CHARGED, THEY HAVE TO SEE LOTS OF TIMES THERE ARE THINGS ON THERE THEY NEVER ORDERED, THE FAMILIES OF CONSUMERS, WE'VE HAD INSTANCES OF NURSING HOMES WITH SEVERE ALZHEIMER PATIENTS BEING SEEN BY THERAPISTS FOR WEEKLY THERAPY SESSIONS >>OH MY GOD >>AND BILLED, THE INSURANCE COMPANY GETS BILLED AT A PSYCHIATRIST, OR PSYCHOLOGIST STRAIGHT, AND THE PERSON WHO IS IN A NURSING HOME CAN'T COMMUNICATE WITH ANYONE >>CAUSE HE OR SHE'S DEALING WITH ALZHEIMER'S? >>RIGHT, AND BUT SOMEBODY'S COMING INTO THAT ROOM FOR TWO MINUTES EVERY WEEK AND BILLING OUT ON, FOR PSYCHOLOGICAL.

>>BUT WHO WOULD KNOW THAT? BUT SOMEONE'S GOT TO KNOW THAT THAT PATIENT HAS ALZHEIMER'S, A PSYCHOLOGIST OR A PSYCHIATRIST IS GOING IN THERE, OR NOT GOING IN THERE BILLING FOR THAT TIME.

>>THE FAMILY SEES THE BILLS.

>>SOMEONE'S GOT TO KNOW IT >>THE ONLY PERSON THAT SEES THE BILLS IS THE FAMILY SO WE HAVE >>AND SO THE.

>>TO EDUCATE, I THINK THE >>AND WE, IS IT JUST.

? >>FAMILY HAS TO BE EDUCATED >>EXCUSE ME, SORRY FOR INTERRUPTING PHYLLIS, IS IT JUST EDUCATING THEM? OR LETTING THEM KNOW THEY'RE IN ON IT? AND THAT'S A PROBLEM? >>WELL, I DON'T KNOW WHY A FAMILY, THE FAMILY BENEFITS >>DO THEY BENEFIT AT ALL? >>IN NO WAY.

THEY'RE NOT IN >>WELL THAT'S INTERESTING >>IN THAT NURSING HOME WHAT DO THEY GET OUT OF IT? >>ARE THEY AIDING AND A.

I HATE TO USE THIS TERM BECAUSE I'M NOT A C.

>>HOW ARE THEY AIDING AND ABETTING THE FAMILY? >>ARE THEY NOT AIDING AND ABETTING SOMEONE WHO IS GETTING A BENEFIT? >>THERE IS NO BENEFIT THE PERSON GOT, THE ONLY PERSON THAT'S GETTING THE BENEFIT IS THE DOCTOR >>THAT'S WHAT I MEANT >>THAT COMES IN >>I'M NOT SAYING THE PATIENT GETS THE BENEFIT >>RIGHT, SO THE FAMILY NEEDS TO LOOK AT THOSE BILLS THAT I GUESS THAT COME >>THAT'S A GREAT POINT >>AND REPORT IT, WHY IS SOMEONE COMING IN ONCE A WEEK AND CHARGING FOR THIS THERAPY? >>LIKE THAT'S A TOTAL SCAM CHRIS, RIGHT? >>ABSOLUTELY.

THOSE, WE HAVE A COUPLE OF CASES LIKE THAT AND LOT OF TIMES WE GET INSIDE INFORMATION, IF SOMEBODY WHO'S EITHER TRANSPORTING THE PATIENTS TO AND FROM THE FACILITY LETTING US KNOW THAT HEY, THE PERSON'S ONLY THERE FOR TEN MINUTES TODAY I DON'T THINK THEY RECEIVED THE SERVICES THAT THEY'RE BEING BILLED FOR >>WHO GIVES THE TIPS? SOMEBODY THAT'S JUST TRANSPORTING THE PATIENT? >>PEOPLE WITH GOOD HEARTS AND WHO UNDERSTANDS THAT INSURANCE FRAUD IS A PROBLEM IT'S A SYSTEMIC PROBLEM SO A LOT OF TIMES WE HAVE SOCIAL WORKERS WHO WILL TELL US LISTEN, MY PATIENT THAT I WORK WITH ONLY RECEIVED 15 MINUTES OF TREATMENT TODAY, TAKE A LOOK AT THE BILLING, MAYBE THERE WERE BILLS FOR AN HOUR, MAYBE THERE WERE BILLS FOR TWO >>JUMP BACK IN >>THE OTHER TOOL HERE IS SOME OF THIS COMES FROM CONSUMER COMPLAINTS OR GOOD CITIZENS >>WHAT DO YOU MEAN? >>THAT, THE TIPS ON FRAUD SOME OF IT COMES FROM CONSUMERS OR THE PROVIDERS OR SOMEBODY WEIGHS IN AND SAYS, WELL THIS EXPLANATION BENEFIT FORM ISN'T RIGHT, BUT A LOT OF IT NOW IS COMING FROM DATA SO WE'RE IN THE ERA OF BIG DATA, YOU SEE IT ALL THE TIME, IT'S BEING USED IN HEALTHCARE BY LAW ENFORCEMENT FOLKS, AND BY HEALTH INSURANCE CAREGIVERS, SO WHAT THEY'LL DO IS THEY HAVE A LOT OF INFORMATION OF THE DATA THEY'LL RUN THROUGH THE CLAIMS EXPERIENCE, AND SAY WAIT A SECOND? DOCTOR SMITH JUST BILLED FOR 26 HOURS IN ONE DAY, YOU CAN'T, YOU KNOW SO THE DATA CAN, YOU WOULDN'T BE ABLE TO PICK THAT UP NECESSARILY BY HUMAN HANDS BUT BEING ABLE TO LOOK THROUGH THE DATA AND THE INSURANCE COMPANIES OR VENDORS THAT THEY USE, WILL RUN INQUIRIES AND SAY, WELL, YOU KNOW YOU KNOW, IF DOCTOR SMITH HAS A PRACTICE IN, YOU KNOW MIDDLESEX, AND ONE IN MERCER WAS HE BILLING AT BOTH LOCATIONS AT THE SAME TIME? >>SO TECHNOLOGY CAN HELP HERE? >>ABSOLUTELY >>AUDITING.

I MEAN THIS AMBULANCE THING CAME FROM AN AUDIT, I'M NOT SURE WHO DID THE AUDIT, BUT >>RIGHT >>SOMEONE PICKED UP THAT MEDICAID OVER.

GOT CHARGED 67 MILLION DOLLARS >>SO PEOPLE WHO SAY TO THEMSELVES, THIS IS AN INTERESTING, PEOPLE WHO SAY TO THEMSELVES "WHAT ARE THE ODDS?" "WHAT ARE THE ODDS THAT I'M GONNA GET CAUGHT IN THIS?" WHETHER IT'S A PROVIDER OR A >>VERY.

>>CONSUMER, OR SOME COMBINATION RIGHT? COME ON! IT'S HAPPENING EVERYWHERE, THE GOVERNMENT DOESN'T HAVE ENOUGH PEOPLE I'M JUST, AGAIN, PLAYING THIS OUT, COME ON? I GUESS IT'S THE IRS ARGUMENT IN SOME PEOPLE'S MINDS WHERE THEY MESS AROUND WITH THEIR TAXES WHAT ARE THE ODDS THEY'RE GONNA GET ME? I MEAN, WHAT ARE THE ODDS? >>THE ODDS.

>>I CAN'T GIVE YOU A NUMBER BUT >>I DON'T MEAN A HARD NUMBER >>THE ODDS ARE.

IT'S.

>>BUT IT'S NOT INFINITESIMAL? >>I WOULDN'T GO INTO A DOCTOR'S OFFICE WITH THE INTENT OF COMMITTING INSURANCE FRAUD AND THINKING THAT THERE WASN'T POSSIBLY AN UNDERCOVER OPERATION GOING ON >>OR YOU DON'T EVEN GO IN WITH THAT INTENT, SAY THE PATIENT, OR THE CONSUMER DOESN'T GO IN WITH THAT INTENT, BUT THE POSSIBILITY COMES UP BECAUSE SOMEONE HAS RAISED WITHIN THE SYSTEM SOMEWHERE, AND THE CONSUMER SAYS, "COME ON! WHAT ARE THE ODDS?" THESE PEOPLE KNOW WHAT THEY'RE DOING, CHRIS, AND I'LL COME BACK TO YOU PHYLLIS WHAT ARE THE ODDS? I DON'T WANT TO SAY WHAT ARE THE HARD NUMBER ODDS >>RIGHT >>BUT PEOPLE ARE CONVINCED SOME OF THEM, THAT YOU'RE NOT GONNA GET THEM? >>WELL, WE'RE TRYING TO GET THEM STEVE, AND IT'S STEAL LITTLE OR STEAL BIG, A LOT OF TIMES LIKE WARD WAS SAYING, THE DATA, A LOT OF THE PROVIDERS WILL TELL US WHAT THE HOT CODE OF THE MONTH IS WHERE THEY'RE SEEING THEY'RE GETTING HIT, A LOT OF TIMES THE MEDICAID FRAUD DIVISION IN THE COMPTROLLERS OFFICE WILL GIVE US A TIP, CAUSE THEY DO DATA ANALYSIS >>SURE >>AND STEAL LITTLE, A LOT OF TIMES YOUR NEIGHBOR WILL CALL AND SAY, "HEY LISTEN, SOMEBODY PUT IN A CLAIM FOR A CAR, BUT I SEE IT SITTING IN THE DRIVEWAY" SO WHAT ARE THE ODDS? PEOPLE ARE ALWAYS WATCHING >>YOU'RE GETTING MORE OF THEM AREN'T YOU? >>WE ARE >>PHYLLIS? >>I THINK YOUNG PEOPLE WHO DON'T USE THE DOCTOR OFTEN OR USE SERVICES, THEY PAY THE BILL OR THEIR INSURANCE PAYS THE BILL, AND THEY DON'T THINK ABOUT IT.

AS A PERSON WHO'S HAD MEDICAL ISSUES MY WHOLE LIFE AND NOW APPROACHING 70 I GO TO THE DOCTOR A LOT I NOW LOOK AT THE HOSPITAL BILLS, I LOOK AT THE DOCTOR BILLS, I'M MUCH MORE CONSCIOUS OF IT, AND OUR INSURANCE PROVIDER AT CITIZEN ACTION HAS ACTUALLY, WHEN HE TALKS TO OUR STAFF ABOUT OUR POLICIES HE TELLS PEOPLE, LOOK AT THOSE EOB'S, OUR STAFF, SO WE'VE HAD INSTANCES OF STAFF, JUST IN THE >>RIGHT >>LAST TWO WEEKS, WHO WENT IN FOR A PROCEDURE, WHO WAS CHARGED SOMETHING TOTALLY UNRELATED TO WHAT SHE HAD DONE >>FINAL MESSAGES, IN THE MINUTE WE HAVE LEFT, FOR PEOPLE AS IT RELATES TO THIS INSURANCE FRAUD ISSUE, WHAT'S THE MESSAGE YOU WANT TO LEAVE WITH PEOPLE BY THE WAY, IF WE COULD ONE MORE TIME, LET'S PUT UP THE IMPORTANT WEBSITE AND PHONE NUMBER INFORMATION, CAUSE LET ME TELL YOU SOMETHING, OUR JOB RIGHT NOW IS TO INFORM, TO EDUCATE, AND GET PEOPLE TO DO SOMETHING, BE PART OF THE SOLUTION.

GO.

FINAL MESSAGE >>WELL, FIRST, I'M GONNA GIVE YOU OUR NUMBER, IT'S 1-800-TELNICB, WE HAVE.

>>WOAH WOAH, 1-800.

? >>TELNICB, T-E-L-N-I-C-B >>OKAY >>THE NATIONAL INSURANCE CRIME BUREAU >>BY THE WAY, THAT WILL ALSO BE ON OUR WEBSITE, SO GO AHEAD >>OKAY.

BASICALLY, IF YOU SEE SOMETHING THAT LOOKS LIKE.

REPORT IT, CALL US, CALL THE ATTORNEY GENERAL'S OFFICE CHRIS AND I WORK VERY CLOSELY TOGETHER ON CASES, MEDICAL PROVIDER FRAUD CASES IN NEW JERSEY >>FINAL MESSAGE? >>FINAL MESSAGE IS INSURANCE FRAUD AFFECTS US ALL IT'S NOT JUST THE BIG CORPORATIONS, IT'S INDIVIDUAL PEOPLE IT AFFECTS, WHETHER IT'S YOUR MONEY, WHETHER IT'S YOUR TIME, WHETHER YOU'RE BEING USED AS A PAWN FOR SOMEBODY ELSE'S GAIN, IT AFFECTS US ALL >>FINAL? >>WE'RE ALL PAYERS OF INSURANCE WHETHER IT'S AUTO OR HEALTH UNIONS ARE, THE STATE IS THROUGH MEDICAID AND THE STATE HEALTH BENEFITS PROGRAM EMPLOYERS ARE, SPENDING IT INAPPROPRIATELY ON FRAUD IS CROWDING OUT OPPORTUNITIES FOR NEW EMPLOYMENT >>PHYLLIS, A FEW SECONDS >>AND IT TAKES A VILLAGE WE ALL HAVE TO BE VERY VERY CONSCIOUS OF WHAT WE DO WHAT WE'RE CHARGED IN AND WHO'S CHARGING US FOR WHAT >>I PROMISE THIS WILL NOT BE THE LAST PROGRAM WE DO ON THE ISSUE OF INSURANCE FRAUD IT IS NOT A VICTIMLESS CRIME AND TRUST ME, IT AFFECTS ALL OF US.

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