“Well if you did, smartass, you’d know they did a piece on health care fraud last Sunday. According to some statistic they quoted, eighty-five percent of people don’t read the explanation of benefits their insurance companies send them. They ended the program by telling people to read everything the insurance company sends them and make sure there aren’t any unauthorized charges.”
“I see where this is going.”
“That’s right. This morning, everybody in America opened their mail, and a bunch of people we insure are calling to complain about charges they don’t recognize.”
“Is that why it’s so noisy here?”
“Yes. The company is getting inundated with phone calls, and the call centers can’t handle them all. Everyone is taking calls from angry people screaming about fraud on their insurance policies. I mean everyone, too. Claims examiners, underwriters, and account managers are all answering the phones.” The Old lady pointed to the ceiling. Even You-Know-Who.”
DiMauro glanced at the ceiling. Carlton Bremler’s office was on the thirtieth floor. It must be bad if the CEO was taking customer service calls. “Okay, so how many of these calls are really the result of bogus claims?”
Ursula piped up. “All of them.”
“All of them?” DiMauro couldn’t believe that. “There were over a thousand emails on the tip line.”
“More than that. Garret and I have been reviewing claims since we got here at eight this morning.”
The Old Lady said, “I talked with the Head of Claims. Last week, the company paid three hundred thousand dollars above the usual payout. That’s probably how much they paid in fraudulent claims.”
“Three hundred thousand dollars over the norm in one week?” DiMauro said. “Why didn’t they report it to us sooner?”
The Old Lady grunted in annoyance. Then, “They count on their damned computers to tell them when something is wrong. None of those idiots can actually think for themselves. The claims didn’t trip any of the filters. There were no red flags, so they thought everything was fine. That is, until the phones started ringing off the hook.”
“That’s ridiculous. An extra three hundred thousand dollars in claims is suspicious on its own.”
Ursula said, “Not necessarily. This company pays out millions for medical claims every month. Three hundred thousand is within the variance.”
“Bullshit,” DiMauro and the Old Lady said simultaneously.
DiMauro pointed to the Old lady. “Jinx. You owe me a soda.”
“Shut up.”
“So what do we do now?”
“This company has spent millions on computerized fraud detection, security filters designed to spot suspicious claims and flag them for review. Somehow, these claims slipped by all of them. We have to figure out how. That’s number one. Number two, we have to figure out who the fraudsters behind this are and shut them down.”
CHAPTER TWENTY-ONE
Gil stared at his computer monitor, skimming through the headlines of online news sites.
PRESIDENTIAL CANDIDATES GIVE OPINIONS ON LATEST MIDEAST CRISIS
UNEMPLOYMENT UP, JOBLESS CLAIMS DOWN, ECONOMIC NEWS GRIM BUT HOPEFUL
THE ROLLING STONES LATEST “FAREWELL TOUR”
Another one?
LATEST MOVIE REVIEWS: AVENGERS, BATMAN, SUPERMAN
There are a lot of movies about guys in tights and capes this year, thought DiMauro.
CELEBRITY SEX SCANDAL
He definitely wasn’t going to find what he was looking for here. Unfortunately, this is where he stopped when he heard, “DiMauro! Goddamnit!”
“Jesus.” Once again, he nearly leapt out of his chair. “Haven’t we talked about that?”
“You’re supposed to be researching those bogus claims and figuring out how they’re getting past our security, not reading about some broad on TV who got caught in a gang bang with the New York Giants.”
“Ursula and Garrett are handling that. I’m doing something more important.”
“More important?”
“Yeah. Didn’t you say we needed to find out who was behind this? I’m looking into news reports for any info on the data breach. That’s the best way of locating these fraudsters.”
“What data breach?”
“Are you new at this? In order to create bogus insurance claims, the fraudsters need patient information like names and addresses and social security numbers. That data had to come from somewhere. Three hundred thousand dollars means hundreds, if not thousands, of patient’s’ personal data was stolen. A data breach that large can’t go unnoticed.”
“I mean what makes you think there was a data breach from a single source. Couldn’t the data have been stolen from multiple sources?”
DiMauro shook his head. “Nope. If the crooks were getting the data piecemeal, then claims would be coming into the office a little at a time. Instead, we got hit with them all at once. That means one single data source.”
The Old Lady slapped him on the shoulder, enthusiastically. “I think you’re onto something. So what did you find?”
“Nothing.”
“Nothing?”
“Not a damned thing. Either the data breach hasn’t been discovered yet, or it’s being covered up.”
“Well, that was a big waste of time. At least it’s not all bad news. I’ve been calling around to some of my contacts with some other insurance companies. Officially, they aren’t saying anything but, off the record, I got some to admit they’ve been hit as hard as we have, some even harder.”
“How is that good news?”
“It means Bremler isn’t the source of the stolen data. If it were, we’d be the only insurance company getting these phony claims.”
“Good point, I guess.”
“My office. Now.”
She began marching towards her office, and DiMauro got up to follow. “One of these days, you’re going to say ‘please’ and I’ll drop dead from shock.”
The Old Lady stopped in her tracks and turned around. “Please.” When DiMauro didn’t immediately respond, she said, “Yeah, I knew you were bluffing.”
They found someone waiting for them when they arrived. A man in a gray suit with a shaved head stood with his arms folded, staring out a window in the Old Lady’s office. He turned to face them when they arrived.
The Old Lady said, “This is Gil DiMauro, my senior investigator.”
“Nice to meet you,” Carlton Bremler said. In fact, DiMauro had met the CEO previously but didn’t bother to point it out. Neither man offered the other a hand. “I’ve been apprised of the situation. It looks very bad for the company. I’d like to know what is being done about it.”
“This is a sophisticated fraud ring,” the Old lady said. “There is very little chance we’ll ever recover the money we’ve lost. Our best bet is to stop any future bogus claims. DiMauro has a theory that the patient data used in these bogus claims came from a single source. I think he’s right. If we locate that source, we’ll be able to identify the fraud ring and shut it down.”
The CEO didn’t seem happy with that answer. “It sounds like this may take some time. In the meantime, we’re still vulnerable. Is there anything I can do to help? Do you need more staff or resources?”
The CEO must really have been worried. Normally, the Old Lady had to fight tooth and nail for every paperclip. The company hated spending any money on the Fraud Unit. The Old Lady and her staff might save the company a million dollars or more every year but those savings didn’t show up as profits, so the company usually didn’t give a damn. The Old Lady actually preferred it that way. She was much more productive with a small staff, a tiny budget, and no corporate pencil-pushers looking over her shoulders. “We don’t need anything now, but I might take you up on your offer later.”
DiMauro decided to give his two cents. “I think we should call Johnny.”
“Johnny who?” The CEO asked.
“Johnny Chavez,” DiMauro explained, “is our usual contact with
the FBI.”
The CEO shook his head. “I’d rather we didn’t do that if we don’t have to.”
DiMauro didn’t like the sound of that. “Insurance fraud like this comes under the heading of mail fraud and wire fraud, which makes it a Federal case. We have to report it.”
“I understand that, but do we have to report it now? Can we do our own investigation first?”
Now DiMauro was really nervous. This almost sounded like he was being asked to take part in a cover-up. “Well, I guess we could wait, but why? Other insurance companies have been hit, so the FBI may already know something. We could coordinate and share data.”
Carlton Bremler leaned close to DiMauro and put a fatherly arm around his shoulders, which made DiMauro even more nervous. “Mr. DiMauro, do you know what the single most important asset any insurance company can have is?”
“An espresso machine in the breakroom?”
“Its reputation. Once that’s been sullied, it can take years, even decades, to repair the damage. You can see that, can’t you?”
Sullied? Who talks like that? “Uh, I guess.”
“Good.
“But we can’t keep something like this secret.”
“I’m not proposing we do. The company has paid hundreds of thousands of dollars in fraudulent claims. Nothing can change that. However, if we can find this fraud ring and shut it down on our own, that will show we can take care of business. That will go a long way in bolstering our shareholders’ confidence.”
The office door burst open and Ursula bounced in. “Who’s a genius? This gal … oops.” She skidded to a halt when the saw the CEO. “I’m sorry. I didn’t know you were in a meeting.”
“Please tell me you have good news,” the Old lady said. “I could really use some about now.”
“I figured out how the claims are getting past our security filters.”
“Excuse me,” the CEO said. “What security filters?”
It irritated the Old Lady to no end that the man running this company knew so little about how insurance companies worked. “We have programs that identify suspicious claims and flag them for review before payment. You know how a credit card company reviews your purchase and calls you if they see anything out of character? For example, if you normally only use your credit card to buy books or groceries and then, one day, they see a charge for a five-thousand-dollar computer, they won’t authorize the charge until they contact you and make sure your credit card wasn’t stolen. Well, it’s the same principle. The filters review claims to make sure they’re consistent with previous medical history.”
“That’ sounds very clever.”
“It’s more than clever,” DiMauro said. “Those filters are brilliant. I should know. I wrote them.”
Ursula cleared her throat. “Uh, we wrote them.”
“I wouldn’t sound so smug if I were you,” the Old Lady said. “Considering they seem to have failed miserably.”
Ursula said, “But that’s just it. They haven’t failed. All the fraudulent claims we’ve received are totally consistent with past medical history. If a patient has a history of diabetes, then the bogus claim is for diabetic supplies. If the patient has a heart condition, then the claim is for a pacemaker. Somehow, the fraud ring has gotten ahold of the complete medical histories of these patients, and is sending in phony claims that match.”
DiMauro plopped down into one of the Old Lady’s guest chairs and clasped his hands behind his head, looking very smug indeed. “Well, now we know.”
“Know what?” the Old Lady demanded.
“Where the data is coming from. It’s the health care providers. It must be.”
“Now wait a damned minute. You just got done telling me the data breach must have been at a single location.”
“That’s right.”
“Well, I’ve checked, and a lot of these doctors and therapists and clinics are totally unrelated to each other. How can there be a single data breach when none of these providers share data?”
“I don’t know.”
“Well, that’s just great!”
“The providers are the only ones with that kind of medical info. They have to be connected, somehow.”
“Okay then, let’s find out how. You two start paying a visit to some of these providers. Start with ones in the city and work your way outward. Tell them Bremler is just doing an audit. That’s the official line. Unofficially, I want you to snoop around and see what these places have in common.”
DiMauro said, “Hey, maybe they all use the same employment agency.”
Ursula suggested, “Maybe they use the same billing software or the same tech support. Anyone with access to the billing computers could easily slip in a keystroke logger.”
“Whatever it is, find out,” the Old Lady snapped. When the investigators didn’t move right away, she added, “I mean now. Move.”
They moved.
“It sounds like you have everything under control,” the CEO said when they were alone. “Please keep me apprised of your progress.”
She wanted to tell the pompous, self-important, do-nothing to go stick his face in a fan. The Old Lady was a hard case by nature, and office politics did not come easy for her. Her impolitic nature had dogged her throughout her career on the police force, and it dogged her at Bremler Mutual. Nevertheless, she clenched her jaw and said, “Thank you. I will.”
CHAPTER TWENTY-TWO
Although the quote has been attributed to him on many occasions, New York Yankee Yogi Berra never said, “Nobody drives in New York. There’s too much traffic.” Regardless of who said it, that was an accurate description of driving in New York City. San Francisco wasn’t quite so bad, but driving, and especially finding a parking place, were still a colossal pain in the ass. Particularly in Chinatown where the streets were regularly clogged with aimless tourists looking for a place to eat, and hardworking merchants who had neither the time nor inclination to worry about traffic laws. Both Gil DiMauro and Ursula Randall were longtime residents of the city and knew this, which is why they chose to take the bus to their first destination.
The Yang-Hsing Health Center located behind an old-fashioned, pebble-glass door was situated between a fish market and one of those tourist shops that sells T-shirts, snow globes, and paper lanterns with pictures of the Golden Gate Bridge. Despite, or perhaps because of its location, there was no hint of Eastern medicine in the lobby. The gleaming white walls decorated with bland watercolors, and a table covered with old National Geographic magazines were designed to make a “Western medicine” statement. DiMauro knew from reviewing the center’s claim history that they didn’t even dabble in the few Eastern treatments that were covered by insurance, like acupuncture. While white Americans were increasingly enamored of “alternative therapies,” including Chinese medicine, more and more Asians in America were eschewing traditional Chinese medicine in favor of Western science.
A pretty Chinese woman in pink scrubs sat behind the front desk. She looked up as they approached.
“We’re with Bremler Mutual. We called about doing an audit.” Ursula took out one of her business cards but, instead of handing over the card to the woman, she held in in front of her like she was displaying a police badge. DiMauro tried not to roll his eyes. That girl watched way too many cop shows on TV, he thought.
The woman smiled and said, “Yes. We’re all ready for you. My name is Debbie Ling. I’m the office manager. Please follow me.” She led the investigators through the office, past some examination rooms, to a room at the end of a hall. The room held three computers and several cardboard boxes piled up on the floor. “This is where we keep our medical records and also where we do billing. I’m afraid a lot of our files are paper. We haven’t gotten them all digitized, yet, but I can assure you they are all here and all in order.
“This is gonna take a long time.” Ursula said. “We better get started, Gil.”
Ignoring her, DiMauro walked to a corner of the room where he loca
ted a large, orange trash receptacle. It had a lid with a large slot and a padlock. It was a standard shredder bin, used for disposing of paper with sensitive information. He stared at it, seemingly entranced.
“Uh, Gil, can we get started, please?”
DiMauro slowly stuck his hand into the slot and then quickly withdrew it.
Ursula didn’t bother to hide her annoyance. “Earth to Gil.”
DiMauro turned to Ms. Ling. “We’re done here. Thank you for your cooperation.
Both women stared at him as he left. Ms. Ling called after him. “But we spent hours getting these records together. Aren’t you even going to look at them?” She gave a puzzled look to Ursula, who shrugged and ran after DiMauro.
She caught up with him outside, where he had his phone out. “What the hell…?”
DiMauro held up a wait-a-minute finger.
A feminine voice on his phone said, “Thank you for calling Dr. Steven Blane’s office. How may I help you?”
“Hello. My name is Gil DiMauro. I’m with Bremler Mutual. We have an appointment to go over your medical records this afternoon.”
“Yes, sir. We’re still getting the records together, but we’ll be ready this afternoon.”
“That’s why I called. It seems we finished with our first appointment earlier than expected. We’re on our way now. We should be there in ten minutes.”
“Ten minutes?” The voice now sounded flustered. “But you weren’t supposed to be here until two. We aren’t ready yet.”
“That’s not a problem. We’ll just take a look at what you’ve got.” DiMauro clicked off his phone before the voice could object further.
DiMauro started walking. Ursula followed, demanding, “What the hell are you doing?”
“My job.”
It was a short walk from Chinatown to North beach, where Steven Blane had his office. It was exactly ten minutes when they arrived. The receptionist was not happy but, as before, they were led to the medical records room. This was a single-doctor operation, unlike Yang-Hsing, so the records room was much smaller. There was a single computer, a scanner, a metal shelf that held paper files that DiMauro assumed were waiting to be scanned and digitized, and a big, orange shredder bin. This time, DiMauro pulled his phone out of his pocket and took a picture of the bin.
Broken: A Leopold Blake Thriller Page 7