It is ashamed that people themselves to be used like that. The 800 dollars compared to the thousands the clinic pocketed is nothing. They should be prosocuted also.
By Amy Silverman
By Olivia LaVecchia
By Monica Alonzo and Stephen Lemons
By Chris Parker
By Michael Lacey
By Weston Phippen
Those tests turned up nothing serious, according to results of the tests obtained by New Times.
But on July 19, two days after sitting for those tests, doctors performed a D&C on Jill Smith. The gynecological procedure diagnoses or treats abnormal uterine bleeding.
A few days after that, all three -- mother and children -- underwent sweat-gland surgery, a sophisticated procedure designed to curb excessive perspiration in the hands. They did so even though their medical records indicate no prior complaints about over-sweating, nor use of prescription drugs to try to curb their alleged problems.
Within weeks after the Smiths' returned to North Carolina, a slew of California medical providers started to submit bills for reimbursement to Penn Western Benefits, of Greensboro. That company administers medical benefits provided by self-insured businesses -- in this case, the hosiery mill where Jill Smith then worked.
Penn Western oversees the health-insurance benefits of 70,000 people, which makes the firm relatively small in the industry. And it doesn't have an investigations unit. But its lack of size often allows one person to track an insurance claim from start to finish, as contrasted with larger insurance companies.
The medical bills from Southern California for the Smiths landed on the desk of Penn Western claims consultant Cathy Brady.
The total billed for mother and children: almost $350,000.
Along with the bills, St. Paul sent a letter dated July 30 from the Accreditation Association for Ambulatory Health Care, a credentialing organization based in Wilmette, Illinois. Written to St. Paul medical director Martha Madrid, the letter said the association had voted to award the clinic a six-month accreditation.
But Brady says she soon became very suspicious of the staggering claims, especially when she saw the inexplicably distant site of the surgeries and the lack of proof of their medical necessity.
"We're not in the business of rejecting valid claims," Brady says, "just the opposite. But this was the rent-a-patient scam that I had read about. I told a guy at the California Department of Insurance fraud unit what was going on. He said, It seems more like an insurance coverage issue than anything else.' He was wrong. This was about a criminal enterprise."
Adds Brady, whose two brothers are in law enforcement and whose late father was a police sergeant, "I'd love to be a police investigator working on this scam because it's amazing on so many levels."
Brady's own sleuthing led her down many paths over the next several weeks.
She says she phoned Premier Wellness, the Westminster, California, clinic where the trio had undergone myriad tests from July 17 to July 21.
Brady says a woman at the clinic told her the Smiths had been "very, very sick" when they'd arrived from North Carolina, and had needed the tests on an emergency basis.
On July 17, Jill, Bobby and Michele Smith reported to Premier Wellness for what the on-duty doctor, Kevin Tien Do, later indicated were "checkups."
Dr. Do's summary of Bobby's medical condition, which New Timesobtained, said that the boy had complained of "dizziness, headache, lightheadedness and chest palpitation, chest pain and jaw numbness. . . . Patient also complains of abdominal pain and indigestion, diarrhea and constipation and fever."
Do also noted 14-year-old Bobby's complaints of "restless legs" and assorted other maladies.
But the doctor jotted down nothing in Bobby's chart about complaints of excessive sweating.
Do's summary of 16-year-old Michele was akin to her brother's, with the addition of "headache constant, dull aching" to the mix.
Again, nothing about perspiration came up in his report of Michele's physical condition.
Do wrote that Jill Smith "is here for experiencing lower back pain for three months. Pain has been more constant, dull, sharp, with occasional radiation to leg. Complains of leg cramp, leg pain, numbness/tingling. In addition, patient has been complaining of occasional shortness of breath, chest pain (dull), worse with exertion, dizziness, room-spinning, falling, fatigue, insomnia."
That was it. Smith apparently made no complaints about sweating too much, nor about any gynecological problems.
That day, the three underwent testing for all manner of things -- heart palpitations, abdominal pain, sinus problems, dizziness and giddiness, headaches, vertigo, carpal tunnel syndrome, and others.
Total billed by Dr. Do to Penn Western Benefits for the visit -- about $80,000.
The next day, July 18, records show that Dr. Joong Kim completed his own history and physical of Jill Smith at the St. Paul clinic on Beach Boulevard.
On Saturday, July 19, Dr. Kim performed a D&C on Smith at St. Paul, allegedly because of her troubles with excessive menstrual bleeding. The clinic later sent a $34,000 bill to Penn Western for that procedure, almost all of it for "facility fees."
Joong Kim billed Penn Western $1,700.
Brady wrote to herself a few months later that Dr. Kim's preoperative notes had been "very sketchy." She added that the doctor should have ordered other tests and placed Smith on hormone therapy before doing a D&C.
Remarkably, just hours after Smith's D&C, during which she had been rendered unconscious with a general anesthetic, she returned to Premier Wellness. There, she underwent a "sleep study" monitored by Dr. Do for alleged apnea problems.