"The coroner's report finally came back, Don, but it doesn't tell us anything we don't already know. Two 22 caliber bullets in the head," Colby said, when Don came into the command center the next day for his daily status report.
Don nodded, there was nothing unexpected there, "What about the death threats? Anything there?"
"There were death threats on the audio as well, the same voice each time. Says pretty much the same thing as the letters. Looks like generic 18# general purpose paper you can get at any office supply store. I'm trying to find out if it's possible narrow down the printer model that produced the letters. Hague must have thrown out the envelopes the threats came in, none were found at the scene. It would have helped in isolating where they were mailed from."
"What about the off-shore accounts?"
"Well, they're being as helpful as they need to be."
Don frowned, "What does that mean?"
"They're providing us information with the accounts as it pertains to the US. They're not divulging any information regarding transactions that go to other off-shore accounts or to Swiss numbered accounts, at least, not unless we have specific account numbers for them. So following the money trail has been a little slow going."
Sighing, Don nodded to Colby, "Alright, just keep at it. We want to take advantage of you being on restricted duty to get as much done on this case as we can. Once you're back on field duty, it'll be split time again."
Colby looked hopefully at Don, "Any news when that will be?"
"Just a few more days, Colby," Don felt for the younger man. "Are you going to get started on the videos that Charlie, re.. um.."
"Re-encoded. Yeah, I'll get started on that in a bit. Maybe we'll get lucky there."
Don turned to Rilla, "How's Charlie coming along with the data?"
She smiled sweetly at him, "Good morning, Agent Eppes, I'm fine, thank you for asking."
Colby stifled a grin and turned to his own work. Robin didn't have any qualms about it, she laughed at the chagrin on Don's face.
Rilla continued, "Charlie isn't too happy with me for changing some of the criteria, but the updated algorithm is in place, and they've started processing it. They've timed the first gigabyte or so of data, and think it will take at least another day to process the rest of the data."
Don sighed. It had been just one obstacle after another.
"However, Charlie did get me subsets of the data based on those pre-filled claim forms. I looked at chronic dialysis services in particular. Gimbel Healthcare accounts for more than 65 of the billing for chronic dialysis services. That comes out to about $1 billion in billed charges resulting in about $650M in payment received. That's a very high percentage of the overall payment for those services." Rilla paused to catch her breath.
"Why hasn't anyone noticed any of this before?" Robin wanted to know.
"I'll get to that in a minute. This old woman has to follow her train of thought before it leaves the station."
Colby laughed, he couldn't help it. Rilla glared at him. He grinned unrepentently back at her.
"I did a quick SQL query," Rilla held up a hand to forestall any inquiry about the unfamiliar term, "for all the patients that showed up for Gimbel Healthcare to see what other claims came up for them, and found that their dialysis supplies all came from Brentwood Supplies and Durable Medical Equipment. I think it would be a good idea to find out what the relationship is between the two companies. Looks like kickbacks of some kind."
Rilla looked at Robin, "Medicare claims are not processed at a central location. They're contracted out to insurance companies, or third party administrators. It's quite an effort to ensure that payments are made correctly and in a timely fashion. They don't really have the time or the luxury to run statistics on their data. Plus, it would require a look across all of Medicare claim processing to provide any meaningful information on trends."
"Why is there such a huge difference between the billed charges and the payment received?" Colby was curious.
"Well, the billed charges is just whatever the doctor decides he wants to bill. There are charts of what is called 'usual and customary' or 'reasonable and customary' fees for all the services that the medical industry can provide. These are by zip code. Doctors take those amounts and sometimes increase them by as much as 500, and that's what they bill for their services. The insurance companies have contracts with the physicians that determine what amount they will pay for those services. These are called contracted amounts or allowed amounts. Medicare just has a fee schedule that everyone who accepts Medicare has to accept. Then they calculate what benefits the patient is entitled to before they arrive at what payment is due to the physician. Now, if the insurance company decides that a service isn't covered, then the patient is stuck with whatever exorbitant amount that the physician bills."
Rilla looked at the stunned looks on their faces and sighed. "There's more to it than that, but trust me, you don't want to be stuck with a bill from the doctor that the insurance company won't pay. Always check with the insurance company about your medical benefits before getting any services."
She looked thoughtful for a minute then smiled, "As federal agents, you're under the Federal Employees Program. I doubt they'll question any of your claims. Especially if they're for injuries in the line of duty."
"Well, I'm sure that's a relief to the taxpayers," Robin said sarcastically.
Rilla laughed at that, then continued, "Well, we can at least get started on investigating Gimbel and Brentwood Supplies. I'm sure Charlie's algorithm will be able to get us the rest of the doctors we should be investigating with less trouble than I had to go through with Gimbel."
Robin nodded, "I'll get the other investigators started on checking these claims with the patients to see what services were actually rendered."