Medical exams with doctors by phone or video hookup are bringing decent, affordable care to millions of people. Seniors with limited mobility or living in isolated rural communities can instantly reach caring doctors for needed tests and exams paid for by Medicare or other health insurers.
Telemedicine is changing healthcare for the better. It’s changing insurance fraud for the worse.
Crime rings are chasing insurance money with increasingly aggressive telemed scams that are stealing billions of taxpayer dollars around the U.S. The ruses aim especially at seniors — peddling unneeded back braces, fake DNA tests and other useless health benefits falsely charged to their Medicare accounts. The stolen insurance money is reaching record levels, and rising.
Part of $1.2-billion looting
Which leads to telemed mogul Lester Stockett. The Medellin, Columbia man ran an international network of telemedicine firms and call centers that recruited seniors into one of the largest accused health-fraud crime rings ever — a $1.2-billion looting of Medicare. Stockett was responsible for $424 million of the charged ring’s taxpayer losses.
His crime is an urgent alert for seniors to be wary of high-pressure phone sales pitches and medical exams for free medical benefits that aren’t so free after all.
Recruiters, brace suppliers and others kissed Stockett’s imperial ring with bribes so corrupt doctors on his payroll could prescribe useless braces and loot the Medicare money that fattened everyone’s bank accounts.
Stockett’s telemed firms operated under the umbrella name Video Doctor Network. His spiderweb of call centers phoned Medicare seniors from boiler rooms in the Philippines and across Latin America. They reached hundreds of thousands of seniors, many who were disabled. Stockett sold them false hope for a better life.
Doctors gave bogus phone exams
His phone callers convinced the seniors to accept free arm, back and neck braces — whether or not the seniors needed the equipment.
The call centers next transferred the trusting seniors to Stockett’s telemedicine firms for for bogus phone exams by corrupt doctors he’d bribed.
The exams were brief, and the doctors barely asked about the seniors’ real medical conditions. The doctors then prescribed overpriced braces for patients they’d never met and didn’t know. It was irrelevant whether the seniors even needed the braces.
Medical equipment firms shipped the braces off to the seniors, billed their Medicare accounts, and paid bribes to the doctors for their patient exams. The braces often were low-priced Chinese-made equipment billed at inflated prices to Medicare.
In many cases, doctors on his payroll never even bothered to tele-examine seniors. Nor did patients often receive braces — yet their Medicare accounts were billed anyway, the feds say.
Dozens federally charged
The stolen taxpayer money was laundered overseas, and used to buy expensive cars, yachts and luxury real estate.
Dozens of suspects are federally charged. Stockett already took a fall. He pled guilty in New Jersey, and will sentenced in December.
“The extent of Mr. Stockett’s fraud and money laundering literally knew no bounds …” adds Gregory Ehrie, special agent in charge of the FBI’s Newark Field Office. “They stole precious federal funds earmarked to assist the elderly. His admission today should resonate with anyone who is committing fraud against the U.S. government — the FBI will find you and your criminal efforts will not pay off.”
About the author: Jim Quiggle is director of communications for the Coalition
Painfully limping from a seeming job injury, Mandy Henderson left work and started hauling in payloads of disability money as a lieutenant for the Santa Clara (Calif.) County Sheriff’s department.
Henderson convinced doctors she couldn’t do the job a law-enforcement officer needed to keep the peace and sweep bad actors off the streets. Henderson insisted she couldn’t walk regularly, jog a mile in 12 minutes, climb stairs, bend or drive a patrol car.
Sadly, she said she spent most of her days lying on the couch and couldn’t even raise her child normally. Doctors believed her convincing story.
Henderson moved to Las Vegas and retired from the force, presumably nearly crippled by pain and broken-down body parts. The disability money kept coming, helping replace her lost salary and pay for medical bills.
Faked injury, built muscles
In fact, Henderson was a competitive body builder the whole time in Las Vegas. She’d faked her work injury and was plundering the sheriff department’s disability system.
The disability money paid for a fantasy vacation lifestyle that let Henderson sculpt a perfect body at a local gym — courtesy of honest taxpayers. Rippling with muscles, stamina and energy, Henderson competed for body-building trophies. She checked into a local gym 208 times.
The sheriff’s department office back in San Jose grew suspicious and hired an investigative firm to tail Henderson. The firm secretly filmed her living the good life in Las Vegas.
The camera lens caught Henderson working a treadmill and stair climber. She lifted weights such as shoulder and bench presses, and shoulder lifts.
As for child rearing, Henderson easily lifted her kid and drove the car she said she couldn’t drive.
The sheriff’s department asked Henderson to fly back to San Jose for an interview. She begged off, claiming “a lot of pain sitting down for long periods” — such as on a plane.
Pretended pain at meeting
So two officials flew to Las Vegas. They all met at a Starbucks coffee shop. Henderson walked gingerly, leaning on her husband Ken — himself a former Santa Clara police officer. She pretended to have a lot of pain while moving. Midway through the conversations, she stopped to lie down on a bench after complaining of discomfort.
The hammer of justice finally came down hard, and Henderson was arrested. And none too soon. The 41-year-old stood to receive more than $3.3 million of industrial disability retirement money over her full life expectancy.
Henderson had no defense. She pled no contest to making a false claim. She avoided jail with six months of home confinement.
But the price tag was far higher. Henderson’s law-enforcement career is over, she must repay the stolen disability money, and will carry a record of convicted insurance felon wherever she goes.
“She took advantage of a system that is in place to help injured first responders. She should be ashamed for discrediting the sacrifice of law enforcement professionals everywhere,” the sheriff’s department said in a statement. “The true victims in this case are the injured employees that are recovering and actually planning to return to work.”
About the author: Jim Quiggle is director of communications for the Coalition.
Photos form the backbone of billions of dollars in claims. Yet photos can be so easily and convincingly altered that insurers are having difficulty uncovering the deceit hidden in the altered metadata embedded in images used for claims and underwriting.
Forgeries are subjecting insurers to a growing risk of losses from well-doctored images, especially for auto claims. The potential to use readily available technology to slip altered images past insurers has grown exponentially in recent years. Fraudsters thus are increasingly targeting insurers with doctored images to support their crimes.
The emergence of consulting firms that focus on uncovering photo fakery with insurance fraud and other crimes is the marketplace’s way of confirming the problem is real and growing.
Photos are becoming easier to alter. Even consumers with only basic technology skills can use any of the many photo-editing programs that can create professional-looking altered images to scam insurers during policy transactions.
In an era of low- and no-touch policy transactions and claims speeding through the insurance pipeline, the fraud risk from altered photos is growing more acute. The exposure, so to speak, is especially true with more insurers accepting more photos as part of seamless low-touch claims, where scrutiny can be lower.
Many insurers ill-prepared
Photos submitted by claimants can provide pivotal evidence allowing insurers to verify underwriting and claims for millions of Americans. Yet many insurers today are ill-prepared to penetrate well-doctored images that can be easily submitted.
Using free or inexpensive photo-editing phone apps, fraudsters can easily create or inflate car damage by altering the date or time of a claim incidents such as a vehicle crash.
“The days are disappearing when investigators can know a digital image accurately depicts a claimed scene, person or event.”
Instagram, FaceTune, iPhone apps and other widely available photo-altering programs make it easy for most people to alter photos. Thus it’s a small step for people to skillfully manipulate images for insurance cons.
The days are disappearing when investigators can know a digital image accurately depicts a claimed scene, person or event. Defeating burgeoning photo fakes thus takes on added financial urgency in today’s dawning era of low-touch or no-touch claim transactions up and down the insurance chain.
Even modestly tech-driven consumers can easily defeat insurers with well-doctored photos that support false claims, or doctor bogus policy applications during underwriting.
A revolution in manipulating photos taken by cellphones already is underway at the consumer levels. Basic photo-editing tools are standard software on most smartphones. Hundreds of more-sophisticated apps are easily downloadable for free.
Phone software has “beauty modes,” for example, that can alter someone’s appearance. Different eye color, hair color, facial structure and other elements can easily disguise someone.
Mounting losses from fakes happening?
This tech surge comes at an especially challenging time. Insurance fraud is growing, a majority of insurers say in a recent study by the Coalition Against Insurance Fraud. This crime is an $80-billion annual drain of insurers across all lines, the Coalition conservatively estimates.
Without the right tech tools and human skills to detect altered photos, many insurers can expect large and mounting losses as emboldened fraudsters increasingly submit bogus images that stand a high probability of being accepted as valid. Imagine sophisticated criminal rings manipulating photos for large claim dollars, paying well to hire associates with advanced imaging skills.
Photo frauds are relatively easy for average consumers to use with insurance scams. Several photo apps integrate AI algorithms that allow people to add or remove objects in an image, wipe out the background and enhance the appearance of subjects. Here are just two examples of hundreds of easily available techniques: change or mask my location on Android … adjust time and date after capture.
The commercial design app Photoshop is widely used to alter photos for brochures, personal photo portraits, annual reports and the like. Many people have Photoshop skills. It requires training, though is commonly available. A Photoshop user can cleverly change photos to support false claims such as car or home damage, or add injured crash “victims” to a collision scene. I recently talked to an SIU investigator who said he discovered two Photoshoppedphotos in a claim file.
Automobile scams are a persistent, multi-billion-dollar drain on insurers year in and year out. Auto insurance heavily relies on photos, and thus is vulnerable to fakery. Accurately documenting preexisting damage on applications or crash damage during claims, for example, are part and parcel for auto insurance.
“This fraud potential is magnified by the rapid spread of remote insurer photo inspections …”
Altered photos can support almost any false vehicle damage claim. A free or low-cost phone app lets drivers add or enlarge a scratch or dent with little trouble. This fraud potential is magnified by the rapid spread of remote insurer photo inspections replacing on-site manual reviews.
An uninsured driver who rams a utility pole can make it appear the collision happened after she bought a new policy. Simply change the incident’s date and time on her iPhone or Android, then snap a photo. The metadata now reflects the date she selected. She then changes the time and date back to the correct coordinates afterward. When the insurer asks for photographic evidence, the claimant submits the altered image and the false damage claim stands a good chance of being paid.
Imagine a staged-crash ring makes injury claims for seven passengers in a purported two-car collision. Only the drivers were onsite. Yet the ring gives the insurer photos that show five other people at the scene — all doctored into the image, and making expensive injury claims. As with auto damage and repair claims, photo inspections continue to replace in-person site inspections. Larger insurers, especially, are adopting such claims efficiencies.
The core problem is that photography went digital in a less-complicated time. A digital photo is a collection of binary 1s and 0s that are mutually interchangeable: Alter those 1s and 0s, and you can transform the entire photo.
This applies equally to pixilating the image — what it actually displays — and to altering the metadata inside the image file. Nearly all digital cameras embed additional information within the image file. Most smartphones record the time, date and geolocation of the image capture. Data as mundane as the camera model, aperture and exposure times also are recorded.
This metadata should signify accurate, useful information about the context in which the image was captured. Yet current image file formats have no built-in mechanisms to preserve the metadata accurately. Countless tools are readily available online for anyone to manipulate this information and try to defraud insurers. Worse still, tools to manipulate image metadata are built into photo-storage services such as Google Photos.
Insurers and other businesses rely on employees to make underwriting and claim decisions based on what they see. That’s why manual inspections exist in the insurance world.
“Want the image to appear taken last week instead of today? A few clicks start the scam.”
Want to make an image appear it was taken in Europe instead of the U.S.? It’s easy with a little training. Want the image to appear taken last week instead of today? A few clicks start the scam. Imagine inventing a photo alibi for your home arson or other insurance scam. Advancing technology, along with imagination by fraudsters, make such bogus-claim scenarios an increasing threat.
Why not make a false claim for a $10,000 diamond engagement ring that you say you lost at the beach? Or just go to a jewelry store, try on a ring, and photograph it on your finger (with a generic background). Buy coverage, wait the recommended number of days (easily found in an online forum), then claim the “lost” ring. A photo at policy inception with validated metadata (time, date, location and more) can be crucial and convincing evidence of a valid purchase.
GPS data also can easily be manipulated on mobile devices, especially Androids. It’s undetectable unless more-sophisticated checks and algorithms are run at the point of photo capture in a controlled experience. Example: Take a photo from a jewelry shop and spoof the address as your home. Same with furniture.
Digital photos speed claims
Compounding insurer loss exposures is the rapid emergence of low- and no-touch transaction processing along the insurance chain. The customer-centric business model relies on heightened speed, efficiency and auto-processing of transactions.
Faster, easier transactions mean happier customers. This is especially true for rising generations of younger, tech-savvy insurance buyers who expect this efficiency. Lightning speed and ease of use are key to attracting and keeping younger consumers whose incomes and buying power are increasing as they move upward through life.
“… altered photos also can face less scrutiny to keep transactions moving fast.”
Relying on digital photos provided by customers can greatly speed up underwriting and claim-processing times. Yet altered photos also can face less scrutiny to keep transactions moving fast.
Insurers catch many thieves by analyzing a suspect’s photo metadata. Fraudsters also can easily foil investigators with a minimum of knowledge about image manipulation. For example, a scam artist wants the time and date in metadata to reflect a vehicle crash at 3 p.m. yesterday instead of a week prior. Fraudsters can easily change their phone settings and snap a photo. The data forgery is undetectable to an insurer.
Claims and SIU teams are highly professional. Yet they cannot work fast enough to manually detect altered images. Investigators and claims staff don’t have time to manually inspect the large volumes of photos racing in for policy applications and claims.
Deepfakes, altered videos next?
Technology for altering videos is fast-emerging as well. They are less of a current threat to insurers today; manipulating photos remains the primary threat. Still, they point to how rapidly and thoroughly technology is being deployed to manipulate reality.
Until recently, only professionals at major photo studios or design firms could alter videos to such impact. Now AI can help nearly anyone manipulate even a video with considerable skill.
Deepfakes are another looming tripwire. They take image altering to a higher level. Deepfakes are totally fabricated videos or images of people or scenes, yet they seem clear and convincing.Deepfakes are widely circulating on social media, and appearing in mainstream media. They are causing confusion and allowing false information to circulate.
“Will the day arrive when average consumers can manipulate videos and deepfakes in fraud schemes?”
To grasp the full power of deep fake photo manipulation, view these images of imaginary rooms and this invented person. We may not be seeing deepfakes in claims — yet. However, the technology’s rapid spread greatly increases the chances that fraudsters will literally invent photos to support false clams.
Will the day arrive when average consumers can manipulate videos and deepfakes in fraud schemes? Imagine a home or business arsonist editing himself out of his security video, or editing in someone who’s taller, heavier and from a different ethnic group.
Seamlessly check photos
Better prevention, not just detection, is the core of catching photo fakes. Being proactive at the point of underwriting, plus receiving trusted, verified and forensically checked images can prevent more scams.
Insurers are checking more photos for deception. The right systems can seamlessly review photos while maintaining convenient policy transactions for customers. Key is to define the “right system.”
Insisting on in-person inspections for every policy or claim — including photos — costs time and money. This also creates creates high-friction points for customers. Delays and repeated requests for information can make customers feel their truthfulness is being questioned.
Virtual photo inspections are gaining a foothold in response. Customers can upload images from their phones at policy initiation, or provide documentation to back up a claim. Virtual inspections are a step forward in fraud detection, yet the images still are not necessarily trustworthy.
An auto policyholder, for example, says she was rear-ended. The insurer asks her to use its virtual-inspection tool to capture damage photos for the claim. Yet she wants to inflate the damage. So she simply searches the internet for photos of the same make, model, year and color of her real SUV — with the same damage she described. Then, she uses the insurer’s software to capture those images on her high resolution computer screen.
There is no easy way the insurer can tell the photos are fake. So her $14,000 damage claim is paid after the virtual inspection, or maybe her expensive SUV is declared totaled.
Controlled capture can auto-detect
Such scams can be auto-detected, even in a low-touch claim environment. Next-generation solutions — for images, at least — employ a technology called controlled capture, working with image forensics. These solutions reduce the fraud risks of virtual and manual inspections, while maintaining a satisfying consumer experience. Controlled capture can be embedded seamlessly into automated claim and detection workflow. It inspects photos behind the scenes as they flow into insurers.
Controlled capture is the ability to permanently gather all data recorded the moment someone presses the camera shutter button. Image forensics then auto-analyze the device and other metrics to verify the data’s authenticity.
Controlled capture makes it impossible to manipulate a photo’s time, date, location or contents. It can detect fraud beforethe claim is paid. Controlled capture can apply to photos at underwriting, point of sale, claims and SIU. Insurers receive trusted, verified images that discover fraudsters and make everyone happier — customer, insurer and its employees.
Using controlled capture and comparing the phone settings to a secure server at the point of image capture is required to understand these manipulations.
Lack of trust in photos is a mounting problem. All businesses that rely on photos are at increasing risk of fraud. It starts with insurance but extends to home sales, shortterm rentals, online marketplaces and more. Photos thus should never be trusted unless they go through controlled capture and forensic checks.
Many insurance consumers withdraw their claim or policy application when an insurer requests a virtual photo inspection. Or they delete suspicious images from several photos before they (or their agent/broker) send them to the insurer. This might include a manipulated image that shows mold in a house that’s in good condition, or jewelry with the store in the background. Controlled capture will discover these photo schemes.
We’ve entered an era when photos are irreversibly fair game for potentially billions of dollars of bogus claims. Photo-altering apps and claimants’ need for speed have let the genie out of the bottle. As more consumers learn that they can use photo-altering apps to convincingly change images to inflate claims, insurer loss exposures will continue to grow significantly now.
In an era when speed is pivotal in resolving claims, insurers must use that same urgency to detect and deter bogus photos.
About the author: Dan Gumpright is Vice President and Head of Insurance at Truepic. He has worked on high-tech insurance software for 10 years, is a regular blogger, and is a speaker at insurance conferences worldwide.
Shame about Igor Vorotinov’s fatal heart attack, so sad. The putrid body found in the bushes near a rural village in his native Moldova supposedly was poor Igor.
His wife Irina quickly flew in from the U.S., cremated him and interred his ashes in a mausoleum in the Twin Cities, Minn. area, where they lived. She even held a touching memorial service. It was widely attended by members of the local Russian community, who knew Igor well.
Except that Igor used an unknown person’s body to fake his death and steal $2 million of life insurance. Igor spread around bribe money like marmalade to make sure Moldovan officials kept the couple’s ruse moving happily ahead.
Vorotinov bought the policy on his own life in 2010, listing Irina as the beneficiary. An auto mechanic and dealer, Vorotinov then left Minnesota for his native Moldova to set up the insurance theft. It’s a former Soviet republic in Eastern Europe.
Police found his passport, hotel cards and phone numbers on the body.
The responding police officer claimed he had no camera, so no photo of the body was taken. Igor had sadly died of a heart attack, the medical examiner cooperatively said.
Irina hurried to Moldova, identified her dearly departed Igor’s remains, had him cremated, then lugged the ashes back to Minnesota for interment. Irina also had a Moldovan death certificate as proof positive. She gave it to Mutual of Omaha, which sent her a tidy check for more than $2 million.
Irina then opened two bank accounts, one under the name of their son, Alkon. She deposited the money into the accounts, eventually transferring the insurance loot to accounts in Switzerland and Moldova.
Son stumbles on Igor at party
Meanwhile, Igor moved to Transnistria, a small strip of land next to Moldova. He changed his name to Nikoly Patoka and lived there for six years. Alkon then visited Moldova with his fiancee, and just happened on Igor at a party. The stunned kid kept returning to see Igor.
A mystery tipster in Moldova notified U.S. officials that something was up. Officers were waiting for Alkon at the airport when he returned from a trip.
Photos on his laptop showed Igor quite alive more than 2½ years after his claimed death. There was Igor, posing with the young daughter of Alkon’s fiancee in a park. Then again, playing with the girl at a swimming pool. Metadata showed the photos were taken in 2013. And the camera was a Canon IOS Rebel T4i. It wasn’t even available for purchase until June 2012 — more than nine months after Igor supposedly died.
Igor’s supposed ashes were tested, and they were someone else’s. Turns out that Igor also had planted his ID documents on the body, whose identity authorities have yet to reveal. Igor was handed 41 months in federal prison. Irina earlier received three-plus years in federal prison, and Alkon three years of probation.
Someone has to repay the $2 million to Mutual of Omaha. Irina has breast cancer and can’t work. Igor is stuck in jail. That leaves the luckless Alkon, just shy of 30 years old. “He will likely be paying off Mutual of Omaha his entire life,” his attorney Matthew Mankey lamented.
About the author: Jim Quiggle is director of communications for the Coalition.
Halloween was nearing, though fright night seemingly arrived ahead of schedule for Boston-area trolley driver Thomas Lucey.
Someone wearing a Michael Myers slasher horror mask jumped onto the city-run trolley Lucey was driving just before midnight on Oct. 30, 2016. The guy wore dark overalls, and carried a plastic trick-or-treat pumpkin.
Lucey and the masked marauder got into an argument, with the guy saying he didn’t have money for the trolley fare. The stranger hit Lucey in the head, then yanked him off the trolley. He repeatedly hit Lucy while he lay on the ground, then dashed away.
Grainy trolley security video seemed to confirm the claimed attack.
Halloween scream scheme
Except the mugging was a hoax — a Halloween scream scheme. Lucy set up the bogus beatdown to steal workers-compensation money from his employer, the Massachusetts Bay Transportation Authority.
Lucey suffered PTSD and couldn’t work because he was worried about his safety, he said afterward. Lucey complained about frightening flashbacks, depression, panic attacks and anxiety. He had trouble sleeping, and suffered frequent nightmares.
Lucey never returned to work. He sought workers-compensation money to help heal from the seeming trauma. The graphic mugging seemed nightmarish and plausible. So the transit system started paying Lucey workers compensation and longterm disability money — more than $62,000 all told.
In fact, Lucey and a buddy met at a Hooters restaurant three days before the incident to plot out the creepy clash. Lucey promised the guy $2,000. He’d wait in the Michael Myers mask at a pre-arranged trolley stop just before midnight, and pretend to mug Lucey.
Pumpkin prints bust con
The friend was sloppy. He dropped the plastic pumpkin when he fled. Police found fingerprints, which led them to the mock mugger. He folded quickly under questioning, and spilled the plot.
The pair’s bank records confirmed deposits and withdrawals that matched the $2,000 hit fee. Phone records showed they communicated before and after the incident.
Lucey’s reward was three years in state prison for workers-compensation fraud and other crimes. His buddy wasn’t charged.
Lucey was a public employee. He committed insurance fraud to cheat the transport system — and taxpayers. All of that grated on Steve Poftak, manager of MBTA.
His setup scuffle was an “egregious breach of the public trust and a disservice to the thousands of MBTA employees who work hard every day to deliver safe and reliable transit services,” Poftak said.
About the author: Jim Quiggle is Director of Communications for the Coalition.
Street people, hundreds of them, stumbled and tumbled hard onto the pavement around New York City. They formed a gusher of fake falls maneuvered by a crime ring that sued businesses and their insurers for nearly $32 million for aching limbs and joints that didn’t ache at all.
Many of the ring’s recruits were homeless. They often were told to have surgery they didn’t need — even spinal fusions — to increase the payouts from false lawsuits for bogus slip-and-falls. The trip-and-slip insurance shakedown was one of the largest of its kind in recent memory.
Neighborhood scouts lured indigent people off the streets and out of homeless shelters. The recruits needed the money, and were happy to fake injuries for extra cash.
The recruits were arranged at pre-set points around the city. They were coached to fall into potholes and act hurt. Or trip on cracks in sidewalks outside restaurants, dry cleaners and other businesses. They were shown how to pretend they had painful injuries to sensitive body parts that plausibly needed surgery — knees, shoulders and backs. All the better to reap large insurance payouts.
Lawyers sue businesses, insurers
The “victims” were shuttled to colluding chiros and doctors for expensive treatment they didn’t need. Lawyers then entered the picture, and now the big money flowed. The lawyers sued the victim businesses and insurers on behalf of the seemingly hurt victims.
The catch: Patients were told to undergo surgery they didn’t need — usually twice. That greatly hiked the dollar value of the lawsuits. Surgeons wielded scalpels for procedures such as life-altering spinal fusions, knee and shoulder operations, and discectomies.
The low-income patients were desperate for money. The ring paid them tiny sums to get cut up — $1,000-$1,500 per surgery. The patients had a hard time turning down the little windfalls, no matter how much the surgeons sliced them open.
Ring members scout for patients
Bryan Duncan scouted for patients, organized the recruited their legal and medical appointments, and helped procure funding for the recruited patients’ medical treatment and lawsuits.
Robert Locust and Ryan Rainford also recruited patients, drove them to medical and legal appointments, identified potential accident sites, made payments to recruited patients, and coached patients on how to convincingly fake injuries.
The ring finally was euthanized. It was a victim of colony collapse disorder under the weight of investigators who broke open the criminal operation.
Duncan was convicted of four federal crimes — each of which carries up to 20 years in prison. Locust and Rainford each went down with two convictions, also with potential 20-year terms.
$400K ring broken, leader shoots himself
An attorney led a similar $400,000 slip-and-trip ring in Philadelphia. Andrew Gaber hired a small army of recruiters to bring him people he paid to act as phony injury victims. Many were homeless or drug addicts.
The phony victims were coached how to stage seemingly painful falls, and act injured. The fake victims often pretended to trip on small cracks in sidewalks in residential neighborhoods. Gaber’s recruiters acted as witnesses and “injured” victims.
Gaber then filed false injury claims against the homeowner policies. The scam lasted seven years and bilked 21 insurers.
Most ring members pled guilty under pressure from the Philadelphia District Attorney’s office. Gaber shot himself to death before going to trial.
Most slip-and-falls, however, appear to be one-off cons. People fake injuries in department stores, grocery stores, restaurants and other businesses. Yet many stores are loaded with all-seeing security cameras. Phony tumbles thus can be harder to get away with these days.
A New Jersey man claimed he tumbled on spilled ice by the soda fountain in the cafeteria of a business where he did subcontractor work. Jerry Goldinsky filed an insurance claim. Except the firm’s security cam shows him allegedly tossing the ice onto the floor, sitting down and waiting until someone discovers him. Jerry Goldinsky faces criminal charges.
As for the slippery slip ring in New York, federal prosecutor Geoffrey S. Berman had fun at the ring’s expense. “Duncan, Locust, and Rainford were tripped up by the justice system and have met their downfall,” he said.
About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud
Bills forged for skilled nursing, assisted living that patients didn’t even need
Tanned, obsessive and Ferrari-driving, Phil Esformes was a peak achiever as an insurance thief in South Florida. No small feat in a region that’s one of America’s largest hubs of large-dollar insurance scamming.
Running his healthcare empire with an iron fist, the wealthy Miami executive launched a $1.3-billion rifling of taxpayer-funded Medicare and Medicaid. It was one of the largest health-insurance crimes in U.S. history — all at taxpayer expense.
Esformes ran dozens of corrupt skilled-nursing and assisted-living facilities. He bribed doctors to admit patients to his facilities so he could keep the places humming at full capacity.
The operations were mostly super-charged assembly lines churning out bogus claims for services that patients neither needed nor often received. Many patients didn’t even qualify for the care. Others came out of hospital surgery or had mental illness. Medical records were altered or forged to create the illusion that patients needed and received care.
Esformes spent his stolen taxpayer money for a sultan’s lifestyle of luxury cars, a $360,000 watch and a waterfront mansion with a basketball court. Even as his bank accounts fattened, many patients were endangered by substandard care in poor living conditions, the feds contended.
Esformes disguised the doctors’ cash bribes with code words such as “fettuccine.” He inflated Medicare and Medicaid bills to pay for the kickback money he paid.
Bribes worked both ways: Two licensed nurses lavishly paid Esformes to refer his patients to their own health facilities. Guillermo and Gabriel Delgado used the patients to swindle Medicare for bogus mental-health, prescription-drug and home-healthcare services.
The brothers delivered wads of bribe cash to Esformes. They also camouflaged kickbacks as payments for high-end escorts for Esformes, including travel and hotel expenses such as the Ritz Carlton in Orlando.“We will continue the fight against such parasites,”said federal special agent Shimon Richmond.
Gabriel also was Esformes’ conduit for bribing a Florida state health administrator to give him advance notice of surprise visits to his facilities in Miami-Dade.
Cohorts betray Esformes
The dirty money bought no loyalty. Gabriel turned on Esformes when the health mogul suggested Gabriel kill himself instead of face federal charges. Ultimately, the brothers secretly recorded hours of conversations for the feds to try and earn lenient jail terms for themselves.
Esformes also bribed the basketball coach at the exclusive University of Pennsylvania about $300,000 to get his son Morris into the Ivy League academic powerhouse. The coach placed Morris on a priority admission list as a recruited basketball player. The kid wasn’t Division I basketball caliber. Penn accepted him anyway, believing he was an elite player.
Esformes was convicted of 20 criminal counts. The charges add up to potentially 250 years in federal prison. He’ll be sentenced later.
“Even beyond the vital dollars lost though, Esformes exploited and victimized patients by providing inadequate medical care and poor conditions in his nursing homes …” said federal special agent Shimon Richmond. “We will continue the fight against such parasites.”
Honest taxpayers hand over good money to support government employee health and disability plans. Yet millions of tax dollars at a time are squandered when cheaters soak the plans by claiming fake illnesses and crippling medical conditions. New Jersey’s state health plan is the latest victim. Nearly 2 dozen people were convicted in a plot that stole $50 million from the state health system and private insurers. Gooey and expensive compound creams were charged to health plans in the names of employees who were perfectly fine. The stuff was hand-made in specialty pharmacies. It’s often used for scars, vitamins, libidos, fungus, headaches and other things. Tubes of the gunk, in general, can cost $30,000 each or more. Recruiters bribed New Jersey employees with cash to lend their names and policy information for inflated claims against New Jersey’s generous employee drug plan — whether or not the workers needed the meds. Ring members shared in the large insurance payoffs for phantom or unneeded drugs. Teachers, firefighters, police and others are implicated. Prosecutors are coming down hard. Several ring members were convicted, and others remain charged. Dr. John Gaffney often didn’t examine patients, yet signed bogus prescriptions that were faxed to pharmacies. Gaffney faces up to 10 years in federal prison when sentenced. Middle-school teacher Shawn Sypherd recruited employees into the scam. He earned nearly $355,000 total, netting a share of each insurance payout. Sypherd awaits sentencing. A high school guidance counselor pled guilty. Sales reps for large drug firms also helped put the compound meds into play. New Jersey’s state health plan is the latest victim. Nearly 2 dozen people were convicted in a plot that stole $50 million from the state health system and private insurers. Gooey and expensive compound creams were charged to health plans in the names of employees who were perfectly fine. The stuff was hand-made in specialty pharmacies. It’s often used for scars, vitamins, libidos, fungus, headaches and other things. Tubes of the gunk, in general, can cost $30,000 each or more. Recruiters bribed New Jersey employees with cash to lend their names and policy information for inflated claims against New Jersey’s generous employee drug plan — whether or not the workers needed the meds. Ring members shared in the large insurance payoffs for phantom or unneeded drugs. Teachers, firefighters, police and others are implicated. Prosecutors are coming down hard. Several ring members were convicted, and others remain charged. Dr. John Gaffney often didn’t examine patients, yet signed bogus prescriptions that were faxed to pharmacies. Gaffney faces up to 10 years in federal prison when sentenced. Middle-school teacher Shawn Sypherd recruited employees into the scam. He earned nearly $355,000 total, netting a share of each insurance payout. Sypherd awaits sentencing. A high school guidance counselor pled guilty. Sales reps for large drug firms also helped put the compound meds into play.
$600-million disability plot Fake disability claims are another profit-making way to steal from taxpayer health insurers. Kentucky disability lawyer Eric C. Conn pulled off the largest federal disability ripoff in U.S. history — a $600-million looting. Conn bribed a corrupt judge and doctor to rubber-stamp bogus disability claims through the federal system. Conn convinced impoverished coal miners and others in rural Kentucky to sign up. Some knew they were doing wrong, though wanted a lifetime of free insurance checks flowing in. Other workers had legitimate injuries and other medical conditions. The money was their lifeline. Taxpayer money flowed into Conn’s bank account as claims were paid out. He grew rich and built one of America’s largest disability practices.
The feds finally broke open his behemoth scam. Payouts were suspended while the feds investigated. Truly disabled workers lost money they needed for medical and scratch out a living. Tim Dye is a former coal miner — and Conn client with real medical problems. Social Security stopped his checks after Conn was busted. Dye’s wife sold her jewelry and possessions from their home. She even begged neighbors for water to make ends meet.
Other Kentuckians lost their homes, and several committed suicide. Conn lost his freedom, ending up with 27 years in federal prison. Railroad robbed Early retirement on fake disability is another dodge. Public employees have invented bad backs and nerve problems. The painful and debilitating injuries forced them to retire early, they lied. They collected disability checks and fat pensions for the rest of their lives. Only to be caught weight lifting, playing tennis, running marathons, scuba diving and traveling the globe with ease. Employees of the Long Island (N.Y.) Rail Road rushed into early retirement for years, on the backs of well, back injuries and other maladies. Up to 1,500 retirees teamed with physicians and a union official. Almost all claims were approved. The total payouts could’ve exceeded $1 billion if they weren’t caught in time. Pension and disability money fattened the retirees’ bank accounts while they cavorted with few apparent afflictions. An employee claimed ‘disabling’ and ‘unbearable’ pain in a half-dozen body parts when she retired in 2007. Then she was surveilled working out a gym and doing step aerobics. A signalman rode in a 400-mile bike race after retiring. His disability application claimed he was stuck in a wheelchair. An electrician convinced doctors he couldn’t work any more, then was caught landscaping and electrical work for pay after retiring. A top New Jersey official tasked with taking down dishonest insurance claims got it right: It’s our taxpayer money, so we’re the victims. “The cost is invariably pushed onto the public,” says Tracy Thompson, Acting Insurance Fraud Prosecutor for New Jersey.
Hides jewelry, inflates drapery and mural invoices, threatens adjuster
Socialite and political fundraiser Claire Risoldi lived larger than life — and her bank account.
Small wonder the family matriarch also stole large. Risoldi lifted $20 million of false insurance claims after fire chewed through her family’s 5,600-foot mansion in the Philadelphia suburbs. She loaded up a pasha’s ransom of dodgy claims for jewelry, a large ceiling mural, draperies and other bling.
Risoldi’s high-flying social empire finally crash-landed. Investigators found a long trail of bloated claims that convinced a jury she needs serious jail time.
Lied fire fighters stole jewelry
Fittingly, the 10-acre family estate was called Clairemont. Risoldi held extravagant parties and fundraisers for county Republican politicos. She needed the insurance money to keep it all going.
Mysterious fires broke out at Claremont multiple times. Risoldi was never charged with arson, though she went to work with sooty fire claims.
Her biggest deception involved $10 million of supposedly stolen jewelry after the third and final fire in October 2013. Risoldi inflated insurance from $100,000 on two pieces of jewelry to more than $10 million for 55 pieces, just 3 months before that fire. She forged jewelry appraisal documents, repeatedly misspelling the word “jewelry.”
Volunteer fire fighters put their lives on the line for her home. Yet Risoldi accused them of stealing the jewelry from her home.
Then an insurance adjuster found a canvas jewelry bag hidden behind a grandfather clock in the burned dining room, and another bag in a bathtub days after the fire. The empty jewelry boxes in the bags had no soot or signs of water damage. Any fire fighter stealing the jewelry would’ve smudged the boxes with dirty gloves from the smokey interior.
“Snitches get stitches,” Claire Risoldi had her lawyer warn O’Keefe.
And what were bags with 60 boxes of jewelry doing unsecured in her home to begin with, unless she’d planted them for the claims?
Hidden at her rental home after the fire were 20 Rolex watches she’d claimed were stolen.
Inflated claims for ceiling mural
An artist earlier painted lavish ceiling murals featuring Risoldi family members for $50,000. Risoldi convinced him to inflate the cost to $950,000 with forged receipts.
She also handed the insurer 70 forged receipts for replacing wrecked draperies. The firm was called Summerdale Draperies, though Risoldi misspelled the name as “Summerdal” on many receipts.
And Risoldi claimed more than $13,000 a month for a rental home after the fire swept through Clairemont. In truth, the rental expenses were just $4,000 a month.
Insurance money tumbled into Risoldi bank accounts. Family members spent the loot on more homes, six Ferraris, two Rolls Royces, a Shelby Cobra and four other vehicles, all worth $2.8 million.
Threatens insurer adjuster
Risoldi mounted a clumsy and futile campaign of intimidation. In addition to blaming the volunteer fire fighters, she threatened to sue investigators searching her rental home for evidence. Risoldi also publicly called her insurer AIG “cruel” for cancelling her policy. She even falsely blamed the insurer for the fire. AIG should’ve better policed the electrician she’d hired to make repairs after a prior fire, she said.
Risoldi also launched a profanity-laced tirade at AIG’s insurance adjuster James O’Keefe in a parking lot. Risoldi called him a “rat bastard” and “lying sack of …” She had a mole in the Attorney General’s office, she claimed. She knew O’Keefe would get fired and planned to sue him personally, Risoldi threatened. Besides, “snitches get stitches,” she had her lawyer warn O’Keefe.
Investigators exposed Risoldi’s deception and bluster. She’ll serve up to five years in state prison thanks to dogged prosecution by the state Attorney General’s office. Sentencing is being scheduled, and could mean up to 60 years in jail. Her son Carl pleaded guilty and received four years of probation.
Investigators found a book on Risoldi’s desk in her rental home after the fire. It was called, “Insult to Injury: Insurance fraud and the Big Business of Bad Faith.”
“It speaks for itself,” state prosecutor Linda Montag told the jury.
Good choice, bad choice? Community role model triggers debate over ethics of insurance fraud
An educator thought she did an act of kindness for a sick student by scamming a health policy out of $233 to get the kid urgently needed antibiotics.
Casey Smitherman’s choice ignited vigorous debate in her community, school system and prosecutor’s office — making national headlines. She was a public figure and role model who openly admitted she committed insurance fraud — a felony. Yet she had seemingly good intentions, and made no personal profit.
So what to do? What would you do?
Drove student to clinic
Smitherman was the superintendent of Elmwood school district, about 30 miles northeast of downtown Indianapolis.
A student didn’t show up for class. Concerned, Smitherman went to the 15-year-old’s home to check up. He seemed to have strep throat. The teen lives with an elderly relative who doesn’t drive. So Smitherman drove him to an emergency clinic for antibiotics.
The pharmacy refused to provide her the meds; the student was a minor, and Smitherman wasn’t his legal guardian. So she drove to another clinic. She lied the youth was her son, obtaining the antibiotics under her own son’s health policy.
The student’s guardian went to the police. Smitherman quickly admitted all and cooperated. She was charged with insurance fraud and two other felonies.
“I wanted to do all I could to help him get well,” Smitherman said. “I know this action was wrong. In the moment, my only concern was for this child’s health.”
Avoided jail term
The county prosecutor was empathetic, and cut Smitherman a break. The charges will be dropped if she stays out of legal trouble for a year.
“I think there have to be some consequences, but they shouldn’t be career jeopardizing. I think there’s a way to take care of that without destroying her career, because her motives were good,” prosecutor Rodney Cummings told CBS News.
Many people supported Smitherman on social media. Yet many local residents called for Smitherman’s job.
“What are you teaching our children in this school system? Are you teaching them it’s OK to lie and commit fraud because you felt in your heart it was the right thing to do?” school parent Shay N. Haley told the Herald (Anderson) Bulletin.
Smitherman endangered the student. He could’ve had life-threatening allergies to the antibiotics. The school district might’ve faced serious liability problems, the school nurse Stacey Buck said.
The school district’s state-of-the-art telemedicine system also could’ve handled the youth’s illness on the spot, Buck added.
Prosecutors spared Smitherman jail. In the end, the community and school board wouldn’t spare her job. Committing insurance fraud and using generally bad judgement was too much. Smitherman resigned.
“l am very embarrassed for that, and I apologize to the board, the community and the teachers and students of Elwood Community Schools,” Smitherman said. “I sincerely hope this single lapse in judgment does not tarnish all of the good work I’ve done for students over the span of my career.”