Journal Record Staff Reporter
Health insurance fraud, by some estimates, has become a $50
billion a year industry. Some say it accounts for as much as 10
percent of the spiraling cost of health care.
In recent years, insurance carriers and prosecutors have begun
taking action to combat it.
Thomas W. McLain, manager of the fraud unit for Blue Cross
Blue Shield of Oklahoma, believes that figure is an accurate
reflection of the problem, though he was skeptical back in 1985
when he joined the company to begin the unit.
"I never anticipated the problems from the good ol' boys,"
which he said make up the majority of fraudulent claims. He also
did not expect the scope of doctor-initiated fraud.
He said an accurate portrait of offenders would look like the
famous painting, American Gothic, with the husband and wife
farmers. Culprits are found in just about every link of the
health care chain _ insured individuals, providers, employees and
vendors to insurance companies.
"It surprises me the number of doctors who are in on the
fraud. Lauren White, president of the California Medical
Association, said 5 percent of all doctors are crooks and another
30 percent are overcharging."
Good ol' boys also present a tremendous problem.
"My own father is in that category."
He explained about a time when his son had a lightning damage
claim to his television. The repairman offered to pad the repair
cost by the amount of the insurance deductible. McLain's father
encouraged his son to go ahead and do it and not tell McLain.
"People say that's no big deal, but it adds up."
The cost of that adding is passed along to those who pay the
McLain, who is based in Tulsa, was in Oklahoma City Tuesday
speaking about claim fraud to the Life Insurance Company Office
Management Association. He joined Blue Cross after being required
to retire at age 55 from the Federal Bureau of Investigation,
where he had worked for 30 years and specialized in the
prosecution of white collar crime.
He said during his time at the FBI he only was involved in one
insurance fraud case. It involved a person claiming boats were
stolen when they had not been. Most of the cases he worked on
involved oil field and bank fraud. Health insurance fraud was not
a big issue, but he said it has become one of special priority
for FBI agents as they have become more aware of the problem.
Those who pad their health insurance claims by even just a
couple of bucks find that it is easier to do the next time. Their
confidence then builds up until they move from the "good ol' boy"
category to "cheats" and then "crooks."
During his eight years with Blue Cross, McLain has seen
professors, teachers and even the elderly committing insurance
He described the case of one 71-year-old woman, whom he called
"Ma Barker" because of the extent of her fraudulent activity. …