Comment by word-reader | Hacker News Reader

Comment by word-reader | Hacker News Reader

The scammer ended up with $4M in his pocket, for providing personal training services to 1000 people. Now, it sounds like he would also fraudulently bill the insurance companies for exercise sessions that didn't happen. But let's say only 800 people got personal training: that's $5000 per person. That's not an absurd amount for personal training over a long period of time. And their health was surely improved by the exercise.

Then someone with a personal vendetta against him got his business records because of bad OPSEC. I'm sure a lot of other people involved (clients, business associates) also knew it was a questionable operation, but they were probably pretty happy to have health insurance actually pay for things that improved their health for once. I don't feel like this type of fraud would increase healthcare costs in the way many other actors in the system (who are not about to go to prison) increase them.

If this guy had been ordained as a doctor and was just a little more careful with the billing, he'd be hailed for getting insurance companies to pay for exercise treatment. "You say you have pain? I prescribe 'physical therapy' where you work out with one of my assistants for an hour and I talk to you at the end." Easy as that.

It's kind of a stretch to say that this guy Williams was a hardworking health provider who just wasn't lucky enough to have an approved degree and good opsec. According to the story, his first felony conviction came from using his son's autism to submit fake invoices to get gov't reimbursement (nevermind the felony child abuse that landed him in prison).

And then there's the allegations that he highly exaggerated his services (describing "typical fitness exercises" as treatment for "lumbago and sciatica"). And then there's the several examples of clients who did notice and call out the egregious mis-billing:

> Another client texted Williams with concerns that her United insurance plan had been billed for 18 workouts in December 2015. That couldn’t be accurate, the woman wrote. “I had to take December off due to my work schedule and family in town,” she wrote. “I understand that people need to be paid but this seems excessive.”

The guy is a grifter, no doubt. But the general tone of the article implies that I should be concerned about some random sleazeball for raising my healthcare costs, rather than the insurance companies themselves (who in this case basically administered the defrauding of their client, Southwest Airlines, by not having proper vetting procedures), the MDs who undoubtedly commit the vast majority of insurance fraud, or policymakers.

edit: First-line treatment for sciatica includes typical fitness stretches and "lumbago" just means "back pain" which is treatable with typical fitness exercises: https://www.verywellhealth.com/back-pain-stretches-exercises...

implies that I should be concerned about some random sleazeball for raising my healthcare costs, rather than the insurance companies themselves

We must have read the title differently.

Ah, true. But they had lots of family sources and court records for Williams, and I suppose no spokesperson from the insurance companies wanted to talk, so most of the article is just about him. I wish journalists would develop some more sources inside insurance companies, PBMs, etc. How they operate internally is just like a void that nobody wants to look in to, apparently. Like how do they decide what they'll pay for? Or how do they decide who gets to be part of their network? How long will they let a doctor send in fraudulent claims? There are probably 1000 analysts or programmers inside UHC alone who would happily help answer these.

Or the entire article. Sure, the foreground story is about a serial fraudster, but its substance is the cavalcade of systemic failure to do anything about him, or, by implication, any of the innumerable others like him, bilking the system.

If a system shrugs at fraud, what fraud it suffers is substantially that system's fault, IMO. Obviously, mens rea is a thing, but if you're cultivating an environment where bad actors can act badly, you own a heap of that bad.

EDIT: Phrasing

I think this is a fair point, that the headline suggests a systemic problem, but its narrative is highly focused on one bad player, albeit someone who took advantage of highly exploitable weaknesses. Full disclosure: I used to work at PP years ago and my time overlapped with the author's, so I'm obviously biased. One takeaway I got was that the system is easy to game – particularly in applying to CMS for a NPI number. And apparently, insurers just assume or don't care that CMS does minimal vetting to stop fraudsters. And currently, it seems insurers are optimized to eat the costs (and ostensibly, pass it on to customers) than to actively root it out, which has its pros and cons ("cons" including being overaggressive and making it harder for regular people to get treatments approved.

While the system overall seems ripe for abuse – the story says CMS officials can't recall any instance in which someone has been sanctioned for applying w/ fraudulent credentials, and it's hard to believe that Williams is the first to discover the vulnerabilities – the story ultimately doesn't know the total costs of this kind of fraud.

Several years ago I wanted to learn Olympic Weightlifting. So I hired a trainer and have made good process considering that I was in my mid 30s and have never been active in my life.

These folks are gaming the system and getting something for free, that I've paid thousands of dollars for. That really grinds my gears. As far as I'm concerned his clients are just as complicit in this fraud as he is.

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