Thomas, our first born of five, has always been, not just the oldest, but also the boldest, and the longest and strongest. He still is, but barely so, for nature’s incomprehensible ways nearly snatched him from us. The telling is in how we nearly lost him and how we got him—and he got himself—back.
Throughout his younger years good grades were there to be plucked at will from the vine, and he had a physical agility to match. Perhaps it was his amiability when addressing adults which caused so many to make comments of admiration. Such performance could never really be expected by the parents of any child. Our humble beginnings let us, perhaps more easily than others, see the blessing of the fruits of our labor of eighteen years. The warmth of heartfelt pride filled our breasts.
Varsity swim practice pits lithe and youthful limbs against the water’s resistance for a mile or two each evening, enough to wear out most adults who only watch the churning of their sons and daughters. The rigors of their toil are taken in stride, or “stroke,” five nights a week. Season after season Thomas weathered the drudgery well and shared the victor’s glory with his teammates. Then one evening, as he settled in to study, tiredness overcame him. He spoke of missing tomorrow’s practice then missed the next as well. The “next” turned into the one after that, and soon he knew he would not plunge into the water again. Fatigue gave way to related symptoms, headaches and nausea, and then depression peeked around the corner. He felt that a sad and unfulfilling end was coming to his youthful years. It was with grave misgivings that he reflected on what, for many, would always be their best of times—the high school experience. Throughout the summer he bagged groceries and joked with cashiers and customers but knew that in the fall a new level of studies would loom over him at the university. His foreboding seemed a self-fulfilling prophecy.
To meet the challenge of how to help him outside the confines of our family’s support, we took him to a doctor. A complete regimen of tests were performed, especially blood work. “Could he be on drugs?” we were asked confidentially by a second doctor who did not know his patient as well as we did.
Another doctor or two went under the bridge, and then a psychologist took his crack. Surely the pressures of teenage life, overachieving parents and the first-child syndrome conferred their dire consequences on our son. A prescription to help him sleep came next, and sleep he did, but still the symptoms persisted. After a battery of doctors, there was no end in sight for what was draining his body and soul, his drive and emotions and the passion we had known in our boy cub. So much goodness had seemed to be in store, yet an unsubsiding and all-consuming fatigue plagued him.
Finally, he started college where he’d have four years to make-or-break it, knowing his future hung in the balance. Again, all did not go as planned or hoped. In spite of long hours of preparation, he nodded off in class and, too often, the professors’ words passed him by. He labored through his studies then crashed, waking up as tired as he’d been the night before. He survived the onslaught, but barely. We could do little more than confer with professors and arrange for all the tutoring available for “at risk” freshmen. All you can do is all you can do. It is part of loving your children, no matter what, and suffering quietly with them. Only when the child becomes a parent can he understand how his pains have all been shared throughout the years.
Putting such grief aside to continue our daily work, I delved into healthcare fraud cases in my federal investigations. Organized crime ran medical supply stores sucking the lifeblood from insurance companies that endeavored to make lives whole. Fraud was committed by enormous institutes and laboratories. Some individuals took their shot at beating the system, their well-paid lives too greedy to let health insurance companies, seemingly easy marks, pass by unscathed. Such was one doctor whose specialty was the ear, nose and throat, but whose real glory was in the way he billed as no other before him.
The nasal endoscope was his weapon of choice in the battle to bring home cash. Narrower than a straw and only a bit longer, with an eyepiece for peering, he would place it inside a patient’s nostrils to scan for a few seconds. Done properly—which he didn’t—the charge could be a hundred dollars. But this small amount of fraud was too little for the doctor who sent upcoded claims on unsuspecting patients to all insurers as though he’d dug out polyps the size of grapes. He would bill the same way, patient after patient, visit after visit, at five hundred dollars a clip, having done little more than glanced up each nasal passage. For his efforts he was handsomely rewarded, fifteen thousand dollars a day, $75,000 a week, $18 million over ten years—and all of it was fraudulent!
I first learned of this man when an acquaintance, on a lark, knowing what I do for a living and thinking something might be amiss, forwarded his insurer’s “Explanation of Benefits” for the doctor’s fees to me. Unlike his scores of patients, mine was not an untrained eye. He might have gone on billing this way for years but made the fatal error of doing it on my watch. His life would never be the same, but he didn’t know that yet. With just this one claim to pique my interest, the insurance company’s database was mined to see how his other patients fared. Poorly, we found, when we saw the printout of his billings. Other databases came through, Medicare, Medi-Cal, and any computer we could access without the doctor knowing we were on his trail.
The work of cheating dentists is quite clear. Evidence of their fraud is left for their patients to chew on and to be examined by those ferreting out such scams. But, in this case, we knew it would be the word of one patient at a time against a specialist in his field. Who would a jury believe?
To devise a revealing scenario was the only way to beat him at his game. We found three good souls willing to wear white hats and become “control patients” armed with the finest insurance coverage to whet our doctor’s appetite. The linchpin would be to locate a doctor in the community, and in the same field, who would be willing to help with our case. Finally, the right man was found, with both knowledge and integrity, who would break the doctors’ code-of-silence and help our team. This made him not a Benedict Arnold, but closer to a Nathan Hale in our operation with its revolutionary tactics.
Other problems had to be surmounted. The powers that be don’t allow undercover operatives to endure invasive procedures. It took forever to convince them, if we ever did, that our defrauder billed for climbing mountains but only glimpsed at molehills. Even with all the proper authority, were we good enough to convince the opposition of our genuineness?
The good doctor examined our control patients, first to make sure they were healthy, then before and after each planned visit with the scoundrel. They were assigned “complaints” which had never existed, but supplied a good enough reason to make a first appointment. In seeing our three ringers, unbeknownst to the target, he was deciding his own fate by how he dealt with them. There were naysayers in our ranks, but my money was on the man with the dollar signs in his eyes.
Not wanting to interview his legion of regular patients, many of whom he’d seen for years, we left it to our people to bring light to his dark deeds. We arranged for specialized cameras to be carried into his office in whatever could secrete them and keep the doctor unaware. The control patients could not appear to be from law enforcement so a surfer dude on Medi-Cal, a retired agent, now an ordained minister, on Medicare, and a grandmotherly financial analyst in our office, ostensibly with private insurance, volunteered to be the patients who would attempt to undo the doctor’s best-laid plans.
One merely wanted to ask about an ear condition but needed no treatment. The second had outer ear discomfort from “talking on the phone all day long,” which she didn’t. The last told of a fever blister he had on his lip when he made his appointment, but was now miraculously gone.
What we learned about our doctor astonished even us, for we had only seen the tip of his fraudulent iceberg. All received the peek-a-boo nasal endoscopy, billed to the hilt for even minimal peeking. Other tests abounded. The audiology booth was a favorite stop, and tympanic pressure tests, the next desk over, were administered for no apparent reason. Allergy scratch tests, as many as you’d sit for, and lung-capacity tests were given. None of these were indicated by the control patients’ symptoms and would not have, even if their symptoms had been real. It seemed the doctor would conduct any procedure or give any test which would soothe the savage billing beast that beat within his soul.
Also new to us was the follow-up-visit syndrome. No patient ever left the office without a prescription, and none dealt with the made-up symptoms, anyway. And, always, always, our patients would hear the words, along with a finger pointing at their chests, “I want to see you in three weeks...” “I want to see you in a month...” “I want to check on you in six weeks...” All the concerns of how our people would justify returning for further “treatment” were unfounded. None would ever leave the doctor’s office without what seemed to be a mandatory follow-up appointment.
Well along the way on our prosecutorial mission, we eased off on the control patient visits with nearly two dozen under our belts, each fraudulent action deftly captured on videotape, and always the unnecessary and upcoded nasal endoscopy. At this juncture, I learned our good doctor runs a sleep-study program. Hesitant to mention my son, it was not for another month that I opted to cross a line of sorts and openly discussed his symptoms with our expert. He suggested I get in line for the sleep-study machine, sort of a canister vacuum with a scuba-like tube and mask to band around one’s head for a fitful night of sleep. Thomas made the extra effort to come home from college for the occasion and spent two nights hooked up to the inconvenient contraption. The results, however, when analyzed a week later, told the doctor he did, indeed, have an anomalous sleep pattern with fifteen arousals per hour. When you wake up every four minutes, never reaching the fifth level of sleep where rapid eye movement occurs, your body doesn’t produce and distribute hormones, essential to replenish energy. The task of sleep is undone, and, with these short spans of slumber, Thomas would never recover.
A second, more delineating, test was given weeks later. It was a similar box that produced similar results but was still inconclusive in identifying why his breathing was abnormal. It only told the doctor he awoke too often.
Finally, the boy needed to be seen in the flesh to try to piece the puzzle together. Five months after I’d imparted my son’s symptoms, Thomas, now home for the summer, finally came face-to-face with the authority on the difference between the quick and the sleepy to attempt to learn what ailed him.
A basic ear, nose and throat exam and a review of the sleep study graphs brought an inquiring glance from the doctor. After a short moment he turned to me and, with the dry sense of humor I’d come to know over several months of control-patient visits, said, “You might want to leave the room. You’re not going to like this.”
Like a clangor crashing against the inside of my skull, I realized he planned to do the unforeseen. He would perform a nasal endoscopy on Thomas.
Unlike the man we investigated, this doctor did not take a peek with a little rigid endoscope. Instead we marched to a distant room created for just such occasions. With an intern, a nurse and a full complement of machinery and technical equipment, the doctor brought out his flexible endoscope. It was a few feet of narrow black fiber optics which fell limp across his palm. It attached to a large monitor for all to see. He numbed my son’s passages and explained what was to happen as we waited. Then he carefully inserted it into the right nostril, over the hump, around the bend, past the uvula, down to the tongue, with taste buds visible, and on to the larynx. Every millimeter was like a personalized tour through a primordial cavern, and it was perfect. Then he moved to the left.
In it went, just as before, through the passage, over the hump and around the bend—but there it bumped into a wall and came to a halt. Eyebrows furrowed all around, even the good doctor’s, and he backed off a bit. He tried to skirt the obstacle but there was no way around. We looked to him for an explanation and found a face entranced. His eyes were fixed on the screen, and then went back and forth between my son’s nose and the visual image, leaving the endoscope in place.
He finally looked at me and said, “It’s a polyp the size of a grape. It’s the reason he can’t breathe at night and why he doesn’t sleep.”
He went on to explain that in the evening, nostrils take turns opening and closing. When the left nostril closed naturally, no one was the wiser, but when the right one took its turn, all hell broke loose within his system. He wouldn’t get enough air, and an alarm would go off inside of his brain. An emergency signal would call for oxygen and wake his body, one way or another. For Thomas, this came as a befuddled gasp to suck in air as he tried to nestle down for the night. A polyp—it was as simple as that.
The months must have been hell, the doctor observed. Yes, they were, my son concurred.
How long had it been there? Because of its significant size, probably since midway through his swim season almost two years before. If it had not been found now, what would have happened? It would have been discovered in less than a year—at his autopsy….
“I can’t believe the irony,” I intoned to the doctor who was, himself, astounded at the same point and answered, “Yes, but no one else in the room would understand.”
Sure enough, he’d kept his partnership with us under wraps, just as we protected him, and none of his staff had a clue as to the enormity of what it all meant.
Major surgery to remove the growth came a few days later, and it took much longer than the look-see of the other doctor. But, it was what he’d been charging for all along with his peek-and-bill fraudulence.
The polyp came out, benign as expected, plus a correction to his septum, deviated at forty-five degrees from birth, and the recovery race was on.
I am happy to report that the surgery, the removal of the unwanted grape, was like a light-switch turned on. After several weeks of healing, Thomas came to the breakfast table going on about a dream he’d had. So what was the big deal, asked one of his brothers. Ah, but this was his first dream in two years. It didn’t have to be a great one, or even one he could remember. It just came and was forgotten when he woke up. But, it had surely taken place.
So, if it hadn’t been for a doctor who felt an inner compulsion to lie and cheat every day of his professional career, found out through the thinnest of circumstances by an investigator who beat the bushes to find a crime worth fighting, and a patriotic doctor who could help both our case and, coincidentally, my son, we might never have gotten Thomas back. The nasal endoscopy, the procedure of choice for a doctor who would end up in jail with his assets seized, was the same procedure that saved Thomas for himself and all of us. I will never tell the bad doctor of this because I don’t want him ever to think he has contributed to anyone’s betterment, because he hasn’t. What happened was separate from what he did. It was the silver lining of the dark cloud of his existence. Yet, the irony will remain one of the greatest I could ever know.
Last week Thomas aced a physics test after not having fallen asleep in class, even once. And, it might interest you to know—he is now breathing easy.
Wayne A. Barnes
San Diego, CA