Washington, March 11
Twelve Blue Cross and Blue Shield plans, working with the F.B.I., said Friday that they had broken up an elaborate insurance scheme in which thousands of patients from 47 states were sent to California to undergo unnecessary surgical and diagnostic procedures, for which doctors filed more than $1 billion of fraudulent insurance claims.
Insurance executives and law enforcement officials said that surgery clinics in Southern California typically paid recruiters $2,000 to $4,000 for each patient who received a medical procedure. The patients, they said, received rewards in the form of cash or discounts on cosmetic surgery.
Daniel M. Martino, acting chief of the health fraud unit at the Federal Bureau of Investigation, said the payments to patients ranged from $200 to $2,000 each.
Mr. Martino said the outpatient surgery clinics had billed more than $1.3 billion for services provided as part of the scheme, while insurers and employers had lost $350 million in claims paid to date.
The Blue Cross and Blue Shield plans filed a civil lawsuit on Thursday against nine surgery clinics, 21 doctors and 13 people described as owners, employees or administrators of the clinics. The Justice Department and the district attorney in Orange County, Calif., have filed criminal charges against some of the defendants.
Steven E. Skwara, a fraud investigator at Blue Cross and Blue Shield of Massachusetts, said, "It's astounding, the degree of brazenness of some of the folks perpetrating this scheme." He spoke at a briefing with Blue Cross executives and federal and state law enforcement officials.
William J. Feccia, an assistant district attorney in Orange County, said the patients traveled to California from 47 states.
Mr. Martino, the F.B.I. official, said insurers became suspicious when, for example, "50 people from Boston arrived in Southern California in a three-week period and filed claims for colonoscopies performed every other day."
The civil lawsuit, filed in Federal District Court in Los Angeles, also stated that the plaintiffs - Blue Cross and Blue Shield plans - were puzzled to see "clusters of employees from the same workplace" going to California for the same treatments.
The recruiters often persuaded co-workers to join the scheme. Patients were recruited from small and medium-size businesses, as well as units of corporations like Textron.
In the lawsuit, the Blue Cross plans said that the recruiters located patients, persuaded them to have the procedures, verified that they had insurance coverage and helped arrange transportation to California.
The F.B.I. and the Blue Cross executives said that many patients who traveled to California received three or more procedures in a week. The most common combination was a colonoscopy, to examine the lower part of the gastrointestinal tract; an endoscopy, to examine the upper part of the digestive system; and an unusual procedure to treat "sweaty palms."
Mr. Martino said the last procedure, known as a thoracoscopic sympathectomy, posed potential risks to the patient because it involved collapsing a lung and deactivating a nerve near the spine.
Repeated efforts to obtain comment from the doctors and clinics on Friday were unsuccessful. Millennium Outpatient Surgery Center was named as a defendant in the civil suit filed by Blue Cross and in the criminal case filed by the United States attorney in Los Angeles. Fabiola Sanchez, a receptionist, answered the telephone at the number listed for Millennium. She said that a new clinic, Park Center Outpatient Surgery, now occupied the site, but was not taking patients because "we don't have any doctors yet."
In Irvine, Calif., at the office of a doctor named as a defendant, an employee expressed surprise and said the charges in the lawsuit "make no sense." Another doctor defendant, in Tustin, Calif., refused to take a phone call seeking comment.
The civil-suit complaint includes abundant detail drawn from insurance claims. In a typical case, an Arizona couple had three identical procedures at a clinic in Buena Park, near Anaheim, Calif. On Saturday, March 22, 2003, the husband and wife had endoscopies. They had colonoscopies the next day. On March 29, both had surgery for sweaty palms.
As compensation, some patients got cash and others received discounts on cosmetic procedures including a "tummy tuck," breast enhancement and surgery to correct the sagging or drooping of eyelids, according to the insurers.
The insurers said that doctors had fabricated symptoms and diagnoses for patients, but performed the surgical procedures. Thus, the medical records looked "legitimate or semi-legitimate," Mr. Skwara said.
No patients were named as defendants. But Paul F. Brown, vice president of the Blue Cross and Blue Shield Association, a trade group that helped coordinate the investigation, said: "The vast number of patients knew exactly what they were doing. They did this to get money. They did not need the procedures."
The Orange County district attorney, Tony Rackauckas, said, "Health care fraud victimizes each of us because it raises everyone's health insurance rates."
"At least 1,600 employers had employees who were involved in the fraud" at one clinic, Mr. Rackauckas said. More than 5,000 patients had unnecessary surgeries, he added.
County prosecutors said that owners of the clinic in Buena Park had billed insurers for almost $97 million and tried to hide their identities by creating shell corporations with different addresses and different tax identification numbers.
Mr. Martino said the scheme had apparently first developed among Vietnamese patients, who learned of the clinics at nail salons and from newspaper advertisements. It spread to "the Hispanic community in California" and to assembly-line workers at companies around the country, he said.
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