An oncologist in suburban Detroit ordered “lifetime” chemotherapy, with all its adverse effects, for patients whose cancer was in remission. He ordered it for patients on their deathbed with stage IV cancer. And perhaps worst of all, Dr Fata ordered chemotherapy for patients who never had cancer but believed that they did because of his fabricated diagnoses. Now serving a 45-year prison sentence for fraud, Dr Fata was taken down by a team of Department of Justice (DOJ) prosecutors who included Gejaa Gobena.

Besides personally tackling cases such as Dr Fata’s, Gobena headed the healthcare fraud unit in the DOJ’s criminal division overseeing the prosecution of close to 1000 individuals across the country. Bringing Medicare fraudsters to justice earned Gobena a number of honors, including the Award for Excellence from the Office of Inspector General in the Department of Health and Human Services.

He was interviewed about his work. Medscape just published an article about what he said. “Medicare’s under full assault by fraudsters,” Gobena told Medscape Medical News in the recent interview.

Medscape asked Gobena how and why a tiny minority of physicians are breaking bad, whether it’s cheating Medicare or writing painkiller prescriptions every 10 minutes at an outlaw pill mill. Here are his answers.

Gobena said that the most common factor is financial difficulty. Sometimes it intersects with another factor, which is age. Because you have a doctor in a tough financial situation towards the end of their career, participating in these schemes gives them a way to make some money very quickly. Oftentimes it is personal bankruptcy, or someone who’s been married a couple times, got divorced, has various alimony or child support obligations.

What about medical specialties? Do some types of physicians show up disproportionally in fraud schemes?

Gobena said there were not a ton of specialists that he saw. It’s usually the opposite. He saw a lot of internists billing for tests and services that didn’t make sense and probably should have been billed by specialists in the first place. A  primary care physician suddenly billing for an unusually high percentage of, let’s say, nerve conduction tests. Very expensive, and usually done by neurologists.

Medscape asked about opioid pill mills. “In some cases, you’d have physicians working for nonphysicians. How widespread is that?”

Gobena said it was definitely common in a lot of the schemes that he personally prosecuted or oversaw. It’s a reflection of the fact that until the last few years, the vetting of people who could open a clinic, open a home health agency, was not as strong as it could have been. CMS in the last few years has really stepped up its efforts to screen potential providers. CMS now does criminal background checks. When he first started prosecuting cases, what he saw was people running multiple clinics with no medical background.

One other thing that CMS is doing. In certain regions, they’re putting “freezes” on the ability to open up certain types of services. There has been a freeze in Houston on ambulance companies for a while. There is rampant ambulance fraud down there. So they’re freezing the number of ambulance companies that can be signed up as Medicare providers. Home health, as well, in Houston, South Florida, and Detroit.

In Michigan, it was very easy to open a home health agency if you’re a fraudster. Home health agencies were popping up all over the place, and statistically, it didn’t even make sense when you looked at the population.

Medscape asked about physicians who work for criminals especially where physicians were recruited into pill mills and did the bidding of people who had gangster nicknames and guns. The physicians were pressured, and sometimes bullied, to keep up a certain level of prescribing and not make waves. “That astounded me.”

Gobena said that there are instances where doctors get into a scheme and then can’t get out. They may not want to prescribe the amount of OxyContin or fentanyl that they’re prescribing. It’s often difficult to get out when the owner of the place is a hardened criminal. But I can’t think of any instance when, at least initially, the doctor didn’t voluntarily agree to be part of the scheme.

Many criminal practices employ patient recruiters who offer people fast food, cash, or some other kind of benefit to visit the office and receive services. An example based on a case he prosecuted 5 or 6 years ago, was a general-practice clinic that came onto his radar because they billed nerve conduction studies for 75% or 80% of patients, an outrageously high percentage given that a typical neurologist will perform these on 30% to 40%.

There were doctors who were signing off on the tests. In addition, there was the owner who hired patient recruiters who would go into the poorer parts of Detroit. They would recruit in low-income housing and soup kitchens, offering $50 to $100 to anyone who had a Medicare card to come to this clinic.

The recruiters would coach the patients based on instructions from the owners. The medical records have to show that there is medical necessity for these nerve conduction studies. So they’d coach the beneficiaries to say that they had pain or that their back or arms had tingling sensations, to show that there was some sort of nerve damage. They told the beneficiaries to tell the doctor that.

The doctors would sign off even though it didn’t make sense to have that high of a percentage coming to a general practice having these exact same symptoms. They often would prescribe opioids in addition.

At the end of the day, the doctor was able to bill for their professional services. The clinic was able to bill for the nerve conduction studies, which would run something like $2500 to $3000 a study. The recruiters would get paid by the owners of the clinic. There was an office manager who would help coach patients when recruiters didn’t do an effective job, and help falsify medical records.

“It takes a village to build a fraud.”