Make no assumptions, just examine the facts

In one of the largest insurance fraud scams in California history, a doctor and his team cashed in on hundreds of illegal surgeries. Unfortunately, their case is anything but unique.

Last September, two indictments were unsealed that accused 49-year-old Dr. Munir Uwaydah, his attorney and more than a dozen associates of carrying out one of the largest insurance fraud scams in California history, the Los Angeles Times reported.

According to prosecutors, patients were told a board-certified orthopedic surgeon would conduct their operations. Instead, the surgeries were “performed by a physician’s assistant, [Peter Nelson], who had never attended medical school and was not overseen by the surgeon during the operations.”

The procedures left two dozen patients with lasting scars. Many had to undergo additional surgeries to repair the damage.

“Following a five-year investigation, prosecutors say they uncovered a vast conspiracy in which attorneys and others illegally referred patients to Uwaydah’s clinics in exchange for up to US$10,000 a month,” the newspaper reported.

Nelson conducted the surgeries at an Orange County hospital in 2005, despite being unqualified to do so.

Uwaydah and Nelson were charged with 21 counts of aggravated mayhem — each for a different patient — though the DA’s office said those represent a fraction of the hundreds of procedures Nelson performed.

Among the other accused were workers’ compensation lawyers who received kickbacks to send patients to Uwaydah’s clinics. They got bonuses if the patients were candidates for surgery and more if they received operations, the indictment said. In some instances, even patients were paid if they were reluctant to go through with the expensive surgeries.

“At the doctor’s clinics, a physician documented medical evaluations that never occurred and staff falsified MRI and other records to justify surgeries, some of which were unnecessary,” prosecutors alleged.

The accused also prescribed unnecessary expensive medications and billed two-minute doctor’s appointments as hour-long examinations, the Associated Press reported.

The indictments, which list 132 felonies, name Uwaydah and 14 other defendants, including his physician’s assistant and the billing manager at his medical practice. They “paint a clear picture of a sophisticated and savvy group of criminal conspirators who placed profits above the health and welfare of the thousands of patients they purported to treat,” deputy district attorney Catherine Chon said in court papers. “The callous disregard and extreme indifference that was shown to unsuspecting victims is reflected in the overt acts alleged.”

The case has an even darker side to it. “Prosecutors said Uwaydah fled to his native Lebanon in 2010 after they began investigating fraud as a possible motive in the 2008 strangling of [21-year-old] Juliana Redding, an aspiring model [and actress] he once dated,” AP said.

The Daily Mail reported that Redding’s father, Greg, had cancelled a business deal with Uwaydah five days prior to his daughter’s murder. The deal involved Greg, a pharmacist in Arizona, “managing a pharmacy and helping to develop products for a medical manufacturing company the Lebanese-American businessman had founded.”

Greg, however, had found out that the surgeon, who was known to own property across the world, including at least one Beverly Hills home and a horse farm, had misrepresented himself to Juliana, who was a Maxim cover girl. Through a background check he learned that Uwaydah “was lying about his age, was married and had a family.”

Prosecutors suspected Uwaydah, but they were unable to link him directly to the death. They did charge his personal assistant and office manager, Kelly Soo Park, with the brutal murder after her DNA was found throughout the crime scene. They alleged that Uwaydah had paid her a six-figure amount to rough up Juliana as payback for her father’s decision to end his business dealings with the doctor. Things went too far, they said, and Juliana died.

Two days after Park’s arrest, Uwaydah fled the US. Park, who pleaded not guilty, was acquitted by a jury in 2013.

Park was arrested again in 2015, however, and charged with mayhem in aiding Uwaydah’s billing scheme. If convicted, she could receive a life sentence. Chon said Park placed her name on shell companies and bank accounts for Uwaydah and attended weekly meetings where the doctor and others discussed ways to hide his assets from insurers, creditors and law enforcement.

While few, if any, cases of unlicensed health practitioners conducting medical treatments have a murder twist to them, the California fraud was anything but unique.

A notorious example is Frank Abagnale, a fraudster and con man (and subject of the film Catch Me If You Can). Abagnale, who now helps law enforcement catch fraudsters, once acted as a supervisor of resident interns at a Georgia hospital. “The position was not difficult for Abagnale because supervisors did no real medical work,” an online reference says. “However, he was nearly exposed when an infant almost died from oxygen deprivation because he had no idea what a nurse meant when she said there was a ‘blue baby.’ He left the hospital only after he realized he could put lives at risk by his inability to respond to life-and-death situations.”

A more troubling perpetrator was Rick Van Thiel, who was accused of practising medicine without a licence in Las Vegas in October 2015. Van Thiel had prior felony convictions for robbery, attempted robbery, burglary and assault in 1992 in California, and attempted battery with substantial bodily harm in 2007 in Nevada, according to his arrest report.

The ex-felon described himself “as a former porn actor and producer who follows an anti-authority sovereign citizen philosophy and learned to perform surgery from online videos,” the AP reported.

Van Thiel admitted in a TV interview to practising medicine without a licence for 28 years. He also claimed to have treated hundreds of patients and to have cured cancer and most types of sexually transmitted diseases. He said he has performed abortions and cyst removal surgery. One of the procedures had been posted online.

“A Sept. 30 search of a trailer he used found written records suggesting he medically treated at least 23 people, had written agreements to treat 83 others, and administered injections of the blood thinner Heparin to two people,” according to AP. “Paperwork suggested he performed uterine procedures, dentistry including at least one tooth extraction, and treatments for cancer, HIV and sexually transmitted diseases, police said.”

Van Thiel told an NBC affiliate that he learned to be a doctor from YouTube, books and videos so he could ease the suffering of other people.

At the time of writing he had yet to be sentenced.

Another unlicensed doctor awaiting sentencing is Wilfred Griffith, 64, of Detroit. In February 2015, a US federal jury convicted him for his participation in a nearly US$4.7-million Medicare fraud scheme.

Griffith, who graduated from a foreign medical school but had no US medical licence, was found guilty of one count of conspiracy to commit healthcare fraud and one count of conspiracy to solicit and receive healthcare kickbacks.

According to evidence presented at trial, Griffith worked as an unlicensed physician at Phoenix Visiting Physicians in 2010 and 2011. At that clinic, he treated Medicare beneficiaries and used prescription pads presigned by a physician.

The evidence demonstrated that Griffith also referred Medicare beneficiaries to a Detroit-area home health company called Cherish Home Health Services Inc. in exchange for kickbacks. In ordering the home health services, Griffith used the names and signatures of three Detroit-area physicians to certify that the beneficiaries were housebound and needed home health services, when they did not.

The problem of unlicensed individuals performing medical procedures that require a licensed physician is such that in 2013 the Association of Certified Fraud Examiners named it as one of the “10 popular healthcare provider fraud schemes.” Charles Piper, the author of an article on the subject, wrote: “It’s a scary thought that somebody might impersonate a physician and bill for treatment, but it does happen.” Piper pointed out that the problem also exists in the mental-health community. “I’ve conducted numerous investigations in which medical doctors signed insurance claim forms showing that they had provided all the care but in reality, lesser-educated mental-health professionals actually conducted the therapy.”

Piper cited a case in which he found that a psychological care facility even hired therapists who were not trained to provide those services.

If there’s a lesson for forensic accountants and other fraud investigators it’s that many of us treat doctors and psychiatrists with considerable reverence. This is understandable, as they play such an important role in society. At the same time, however, when investigating a case that could point suspicion at a seemingly licensed practitioner, don’t assume anything about the person. Like a qualified doctor, do a thorough examination of the facts before coming to any conclusion.