Death in Doc’s Sex Trafficking Case; Docs Help Insurer Boost $; Insurers in Court

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Death of Teen at Center of Doc’s Sex Trafficking Case

Questions remain a year-and-a-half after a key witness in a high-profile sex trafficking case against a Miami physician was found dead, floating face down in a South Florida river, the Miami Herald reported.

The death of the witness, referred to as Gina by the Herald, is still a mystery in terms of how she died and why the Miami-Dade State Attorney has not pushed for a thorough investigation of it, the Herald reported.

Subsequent to the death, as part of a deal, Jeffrey Kamlet, MD, an addiction medicine specialist, plead guilty to just one count in the sex-trafficking case — interference with the custody of a minor, as the Herald reported at the time. He paid fines of $750, served one day probation, relinquished his Florida medical license, and was released.

“The criminal case against Jeffrey Kamlet was severely impacted by the death of one victim, the focus of the human trafficking charges, and the unwillingness of the second victim to continue her participation in the criminal court process,” a state attorney statement said at the time, the Herald reported.

Previously, the alleged events in the case dated back to 2022 when Gina, who had just turned 17 and had struggled with mental health issues and substance use, met the then 67-year-old physician on Tinder, the Herald reported. After being found at Kamlet’s condo one night, along with a 16-year-old friend, Gina subsequently told an investigator with the state attorney’s office that she and the physician had allegedly had sex on two occasions.

Ultimately, however, nearly all of the charges against Kamlet were dropped, as the Herald reported. And in a September phone interview, Kamlet told the outlet he did nothing illegal and denied that anything sexual happened with the girls.

Though Kamlet is now facing federal narcotics charges, federal prosecutors have acknowledged that there are significant legal issues with their case, the Herald noted.

Meanwhile, Miami-Dade State Attorney Fernandez Rundle has not discussed the sex trafficking case, though it has been closed since June, the Herald reported.

UnitedHealth’s Docs Helped It Collect Billions From Medicare

Medicare calculates sickness scores — which are used for payment — from information provided by doctors that’s submitted by insurers, the Wall Street Journal reported. And in the case of UnitedHealth, many of the doctors supplying this information work directly for the company.

Overall, sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, “leading to billions of dollars in extra government payments to insurers,” WSJ reported.

Patients examined by doctors working for UnitedHealth had some of the largest increases, WSJ reported, citing its own analysis of Medicare data from 2019 through 2022.

Sickness scores for UnitedHealth patients increased 55%, on average, in the first year in the plans, WSJ reported, noting that this increase was “roughly equivalent to every patient getting newly diagnosed with HIV [and] breast cancer,” according to its analysis.

This figure “far outpaced” a 7% year-over-year rise in sickness scores of patients who remained in traditional Medicare, WSJ reported. And across Medicare Advantage plans run by all insurers, scores for newly enrolled patients increased 30% in the first year.

A spokesman for UnitedHealth told WSJ in a statement that the insurer’s practices lead to “more accurate diagnoses, greater availability of care and better health outcomes and prevention, including less hospitalization, more cancer screenings and better chronic disease management.”

The spokesperson added in part that UnitedHealth’s approach helped to ward off more serious health issues later on and to achieve Medicare Advantage goals of improving quality and reducing costs, WSJ noted.

Mental Health Coverage Denials Go to Court

Many Americans have faced denial of mental health treatment by insurance companies, and a small percentage opt to fight the denials in federal court, ProPublica reported.

Such cases “expose in blunt terms how insurance companies can put their clients’ health in jeopardy, in ways that some judges have ruled ‘arbitrary and capricious,'” the article stated. Court records show that insurers “have turned to a coterie of psychiatrists and have continued relying on them even after one or more of their decisions have been criticized or overturned in court.”

These doctors made “critical errors” that were contradicted by records they claimed to have reviewed, ProPublica reported, citing thousands of pages of court documents, interviews, and insurance records.

Additionally, when insurers have faced pushback about why they denied treatment, they have sometimes shifted from one rationale to another, the outlet noted.

In dozens of court cases, judges ruled that insurers violated a federal law meant to protect individuals who get health insurance through their jobs, ProPublica reported. And in several cases, insurers were found to have gone against a provision in the law aimed at ending discrimination between coverage of mental health and medical claims.

A federal judge wrote in one case that the insurer was “‘applying separate and unequal treatment limitations'” to mental health patients, the article stated.

ProPublica reported that it reached out to six insurers that, according to court records, have continued to rely on doctors who wrongly recommended denying mental health coverage. However, none of these insurers responded to questions regarding whether they take these repeated cases into account or whether there is need for reform, the outlet noted.