The law finally caught up with former Pharr City, Texas Commissioner Oscar Elizondo. He pled guilty to health care fraud at the end of November 2017, and he is just now heading off to prison for a 22-month stint. He has also been fined nearly $1.5 million in restitution to the federal government. The City Commissioner and his insurance fraud scheme thought nobody would get hurt.
Scamming the System
While a commissioner, Elizondo met up with the owner of the Penitas Family Pharmacy (aka the Riverside Pharmacy), which was located in Penitas. Together, they devised a plan to bill Blue Cross Blue Shield of Texas (BCBS) for nearly $1.8 million in fraudulent claims. The claims were for expensive pain patches and scar cream medications.
The scam was quite elaborate and used “marketers” who ingratiated themselves with unsuspecting targets. The marketers, including Elizondo, targeted the employees of with BCBS insurance. They got to know the employees by buying them expensive meals and drinks and then they promised them free pain patches for their aches and pains and scar creams to help them to heal from incisions and such. It sounded like a good deal to the unsuspecting victims, all they had to do was to turn over their personal information which then resulted in the Penitas Family Pharmacy to generate faulty prescriptions, fake claims and paperwork to BCBS.
The victims were assured that they would never have to see a doctor and in fact, the conspirators were so pleasant and generous in buying these folks lavish dinners and alcohol that many of them never received (nor did they expect) the prescriptions.
Most amazing, those victims who did not feel right about getting a prescription without seeing a doctor were taken to a doctor former Commissioner Elizondo personally knew. The doctor signed phony prescriptions and in exchange, the doctor was given cash or phony loans.
In their pitch, the BCBS-covered victims were told that prescription medication was “free.” It was hardly free.
More than the Victims
The system, of course, was failed at numerous levels with this case of fraud. It is impossible to evaluate this scandal without the realization that everyone involved was supposed “ethically trained.” It underscored the inadequacy of the alleged teaching.
Going from the bottom-up, all of us who are on insurance plans in our workplaces are usually warned about making fraudulent claims. In addition, most of us are all too familiar with the dangers of opioid and other painkiller addictions. Most of us are all too aware that agreeing to supply our personal insurance information so that a third party can write a prescription for medication we will never get seems fraudulent at best. We are hardly naïve to the fact that insurance fraud, Medicaid fraud, opioid abuse, and healthcare scams are wrong.
While being treated to a fancy dinner such as the victims were, in this case, might sound nice, no one could have been convinced to give consent to the “marketers” unless they themselves understood what was happening. Each one of the marketer-conspirators understood they were illegally milking the system for profit.
The pharmacists at the Penitas Family Pharmacy are sworn to maintain the highest ethical standards. They fully understand the consequences of their choices. They understand such blatant bending of the ethical, state and licensing rules is absolutely against their training. They will lose their reputations, jobs, and qualifications to ever be pharmacists again.
There was also the physician who wrote fake prescriptions. What was going on in his mind when writing fake prescriptions for fake patients? How much money was needed to entice him to commit this crime, especially in this era of painkiller addiction and death?
Do we place politicians higher or lower than the medical community? They too are bound (theoretically) by ethics, but Texas Commissioner Oscar Elizondo had no need of ethics, rather the opportunity and need to grow a scam.
Rationalization up and down the ladder
At every step of this scam, there was rationalization, that “no one would get hurt.” Truthfully, everyone got hurt, even if “only” a taxpayer. In this fraud, the rationalization destroyed ethics at all levels of the ladder. The current system failed everyone. If the bar is set low enough, if we have no expectations, it is a guarantee that ultimately people will die. The City Commissioner and his insurance fraud scheme begs the question, was it worth it?
