Third Degree

Chapter 8

Kyle Auster sat on the stool in examining room five and silently regarded his nineteenth patient of the day. Arthur M. Johnston. White male, fifty-three years of age, forty pounds overweight, high cholesterol, hypertension, enlarged prostate, erectile dysfunction, history of persistent alcohol abuse, osteoarthritis-the chart went on and on. An intern might look at Johnston’s record and think, This guy is sick, but Auster knew he was looking at a classic malingerer. After working seven years at the now defunct chemical plant, Johnston had somehow talked his way into a full Social Security disability (for back pain, of course). That was a couple of decades back. Now he spent his days cushioned on a carpet of pain medication, watching daytime TV, working in his garden, and taking his grandkids fishing in a boat purchased with government money.

As he droned on about his need for constant pain relief (which only opiates could provide), Auster wondered how he’d gotten to this little chamber of hell. He’d been a goddamn ace in medical school. The only reason he hadn’t specialized in surgery was that he’d had to get out into the real world and start making money. It wasn’t as if he’d had a choice. He had an expensive lifestyle, even then. People had no idea how much money changed hands in a frat house during football season. You could dig a deep hole without ever rolling out of bed.

“What do you think, Doc?”

The patient’s question penetrated Auster’s reverie. “I think you’re doing about as well as you’re going to do, Mr. Johnston. You’re not going to play ball for the Yankees, but you’re not going to drop dead anytime soon either. You’ll probably still be fishing when they bury me.”

Johnston gave a little laugh. “I hope so, no offense. But I was thinking, Doc, you know…. I might need some tests.”

Auster looked back in puzzlement. Johnston had the tone of a patient who’d read some article on preventive medicine in Reader’s Digest. He probably wanted a goddamn sixty-four-slice CAT scan of his heart. “What kind of tests?”

Johnston’s face looked blank as a baby’s. “Well, you’re the doctor. I thought maybe you could tell me.”

Auster’s financial antennae went on alert. He glanced at the upper-right corner of Mr. Johnston’s file, searching for a faint check mark in pencil. There was none, as he had suspected. If there had been, it would indicate that Mr. Johnston was a “special” patient, meaning that he’d undergone some tests that might have been unnecessary in a strictly medical sense, but which had proved lucrative for both doctor and patient. But there was no pencil mark. So what the hell was Johnston hinting at?

“What are your symptoms, Mr. Johnston?”

A sly grin now, minus three front teeth. “Well, Doc, I thought maybe you could tell me that, too.”

A few months ago, Auster would have been happy to oblige Mr. Johnston. Thorough lab work was good, sound medicine, and a chest X-ray never hurt anybody. But given the present state of affairs, Mr. Johnston’s not-so-subtle hints were like the blare of a fire alarm. Auster put on his soberest countenance, the face he used when telling people they had a disabling or deadly illness.

“Mr. Johnston, in the past, I’ve worked with patients to solve their health problems as creatively as I could, given the state of government regulations. But recently the government has taken a dim view of that kind of alternative medicine. It’s become very risky to do anything unconventional these days. Anyone who does could be subject to severe penalties. Abusing the Social Security disability program would be a good example.”

Mr. Johnston blanched.

“Am I being clear enough, sir?”

Johnston was already getting up. “You know, I think I’m doing fine, Doc, except for this back of mine. If you could just renew that prescription, I’ll be on my way.”

Auster stood and patted him on the shoulder. “Happy to do it.”

He wrote out another prescription for Vicodin, then, cursing under his breath, marched out of the exam room and down the hall to his private office. Things were spinning out of control. Vida was doing everything she could to erase all trace of questionable activity, but people kept crawling out of the woodwork with their hands out.

The patients weren’t even the main problem. The real threat was the state’s Medicaid Fraud Unit. Five attorneys, eleven investigators, and four specially trained auditors bird-dogging every medical practice in the state that accepted Medicaid patients. The injustice chapped Auster’s ass no end. Many doctors refused even to treat Medicaid patients, so pathetic was the level of reimbursement. It was the humanitarians who found it in their hearts to treat the poor and indigent who got raped by the government. It made you want to leave the damn country.

Auster knew the Fraud Unit was on his tail. Patrick Evans, his doubles partner on the high school tennis team, was an executive assistant to the governor. Pat was wired into every agency in the state, and a week ago he’d quietly informed Auster that Paul Biegler, the pit bull of the Fraud Unit, had begun investigating him, based on a tip called in to the attorney general’s office. The whistle-blower could have been anybody, but it was probably a disgruntled patient, someone who’d made a little extra money off Auster, then wanted more and got angry after being turned down. Or maybe it was a woman. Auster didn’t get many attractive female patients, but when he did, he wasn’t above a little horse-trading. An ER doc had taught him this racket during his residency. Five Mepergan could get you a hell of a blow job from a strung-out woman, and that beat seventy taxable dollars for an office visit any day of the week.

Medicaid investigations typically lasted months before an indictment, but Auster sensed imminent danger. He felt like a rebel village waiting to be hit by government troops. The blow could fall at any hour of the day or night. The IRS was already auditing the partnership’s Schedule Cs for the past five years, and probably his personal returns, too. God knows what they’d found already. His gambling income was the problem there, although lately all he’d had to report were losses. Auster was a good gambler; he just didn’t always know when to stop. That was why he’d spent a lot of weekends working seventy-two-hour shifts in emergency rooms. Doctors were so reluctant to move to Mississippi that rural hospitals would pay large sums for ER coverage. But Auster was too old to be scrounging extra money that way. His colleagues thought it unseemly, and worse, the work itself was becoming a lot more technical. The standard of ER care was higher. Auster didn’t have time for the continuing-education classes he needed to stay competent in that arena, so that extra income had faded away.

It was Vida who’d helped him replace it. They’d started small, sliding a little cash off the books, for example. What smart businessman didn’t do that? But they’d quickly moved on from there, and soon Auster had found himself making serious misrepresentations of fact. Up-coding Medicaid claims-charging for a Level 4 exam when you’d only spent five minutes with the patient, that kind of thing. But it was the collusion with patients that had really kicked up the cash flow. Vida got the idea from an Internet story about some Korean doctors in New York City. They’d persuaded members of the Korean immigrant community to pretend to have various ailments, then had done loads of tests and procedures on those patients and paid them a fee for their trouble. Vida figured the poorer African-American patients would jump on a chance like that, if Auster put it to them right. But she’d been wrong. Everybody jumped on it in a big way. Not one patient Auster had ever pitched had turned him down. It was a no-brainer. Everyone felt dehumanized by the health-care system and thus eminently justified in screwing it back-just as Auster did. When he thought about how many hours he’d spent with indigent patients for no pay, he had no qualms about finding another way to get compensated for his time.

The Medicaid Fraud Unit wouldn’t see it quite the same way, of course. Guys like Paul Biegler were congenitally blind to the color gray. If I hadn’t pushed it so far so fast, Auster thought uselessly. But he knew enough psychiatry to diagnose his own problem: poor impulse control. Nature had combined with nurture to make him the kind of man who, confronted with a hundred grand in blackjack losses, would double down rather than walk away from the table. He had the same habit with women. Two were better than one, and three better still. Ideally, you had several available at various hours of the day, every day of the week, including Sundays. That way, you moved so fast from woman to woman that you never had to focus on the complications with any particular one. Nevertheless, Auster had somehow acquired two wives along the way, probably because he tended to tell people what they wanted to hear, regardless of his true feelings.

Just now he was managing three women full-time: wife number two, Vida, and a drug rep from Hoche. He had a backup stable of part-timers, but lately he’d been unable to do much there. His problem was Vida. She was the classic double-edged sword: an asset and a liability rolled into one. For an ex-waitress with a year of junior college, she was a whiz at accounting. And she gave great head, no question. But she had some very unrealistic expectations about the future. She’d cling to him like a terrier biting his leg, or in her case, his prick. Vida definitely didn’t fit into any of the scenarios he saw in his future. She probably wouldn’t cause much of a stir in Vegas, but they’d laugh her out of the clubs he liked to frequent in L.A., or even Atlanta.

Auster was thinking of taking out the bottle of Diaka vodka he kept in his bottom drawer when his phone buzzed. He put his hand on the drawer handle, dreaming of the transparent fluid that dedicated Poles filtered through diamonds before bottling it in crystal. One sip could erase an hour’s worth of stress-

“I have a phone call for you, Doctor,” Nell said through the phone’s staticky speaker. “An Agent Paul Biegler, from the Medicaid office in Jackson?”

Auster let his hand fall from the handle. He had the sensation of a sailor who has stared for days over threatening seas finally seeing an enemy periscope rise in front of him. At least it wasn’t a complete surprise. For the hundredth time he congratulated himself on making the right political donations over the years. That was how you stayed wired in this state-in any state, for that matter-and staying wired was how you protected yourself. “Ah, is Vida up there, Nell?”

“No, sir. I think she went out for a smoke break. You want me to try to find her?”

He thought about it. The last thing he wanted was Vida standing at his shoulder trying to coach him through a phone call. This couldn’t be too bad. If it were, Biegler would have shown up at the clinic door with a search warrant, not called him on the telephone from Jackson.

“Did the guy say he was in Jackson, Nell?”

“No, but the caller ID shows a state-of-Mississippi number.”

Auster suddenly had visions of a government surveillance van parked outside his office, a convoy of black cars filled with agents ready to tear his office apart. “Could it be a cell phone?”

“Looks like a landline prefix to me. But I can’t be sure. You want me to take a message?”

Auster didn’t want Biegler thinking he could be intimidated by a phone call. He’d been expecting a surprise search for the past few days. That was the government’s style. They’d show up with a search warrant, a stack of subpoenas, and a team of agents. They’d confiscate your files, your computers, every damn thing you needed to run your practice. They’d act friendly and have “informal” chats with you and your staff, every word of which would be recorded and used against you later. Then they’d stop all Medicaid payments to your business, before you’d had a chance to say one word in your defense. In short, they would ruin you, months before you ever saw a courtroom. Sometimes they even denied you a jury trial. Auster’s lawyer had given him careful instructions on how to respond in the event of a surprise search, but no advice on how to deal with an informal phone call. He would just have to wing it.

“That’s all right, Nell,” he said expansively. “I’ll take the call.” He pressed the button that transferred the caller. “This is Dr. Auster. What can I do for you, Agent Biegler?”

“Hello, Doctor. Nothing today, actually. This is an informal call, for your benefit more than mine.”

Right…

“I’m calling as a courtesy, to let you know that you’ve been the subject of a Medicaid fraud investigation for some weeks now. Were you aware of that?”

“How could I be aware of that?”

A pregnant silence. “Are you one of those people who answers every question with a question, Doctor?”

This might actually be fun, Auster thought. “That depends on the question.”

“Well, up to this point, we’ve mostly been conducting interviews. I wanted to let you know that we’re about to move to the more proactive phase of the investigation, and that’s likely to disrupt your normal business affairs for a short time.”

Jesus Christ. How would an innocent person react? “I’m not sure I understand. Who have you been interviewing? And why?”

“Patients of yours, sir.”

Sir always sounded bad in the mouth of a cop. “Patients? Why have you been talking to my patients?”

The answering silence felt smug somehow. “Do I really need to explain that to you, Doctor?”

Fear and anger rippled through Auster’s gut. “I’m afraid you do.”

He heard paper shuffling. Notebook pages? “Do the names Esther Whitlow, George Green, Rafael Gutierrez, Quinesha Washington, or Sanford Williams mean anything to you?”

Auster swallowed hard against a geyser of gastric acid rushing up his esophagus. Pulling open his top drawer, he took out a half-empty bottle of Maalox and chugged it. “They’re all patients of mine,” he coughed.

“I’m glad we can agree on that, at least. That’s probably all I should say at this time. I just wanted you to know that we’re moving to the next phase of our investigation. We’ve sometimes been criticized in the past for conducting surprise searches. I’ve even heard the phrase ‘storm trooper tactics’ used. In your case, I want to make sure that you have every opportunity to prepare your staff for the disruption. I don’t want you to feel we’ve made our investigation unduly burdensome in any way.”

What the hell is this guy up to?

“In my experience, you need to take certain steps if you want to be able to continue practicing medicine during the investigative process. You’ll probably want to make copies of your business software. I would also suggest purchasing some new computers, since we almost always remove the on-site computers from the practice.”

Auster’s head was spinning. He opened his bottom drawer and unscrewed the cap from the Diaka bottle. A hundred dollars’ worth of vodka slid down his throat as Biegler continued.

“You should photocopy any and all documents necessary for the running of your business, since we’ll probably be taking those away as well. It could be months before you see them again.”

“And when are you moving to this next phase?”

“Eight a.m. tomorrow.”

Tomorrow! “Agent Beagle, I-”

“Biegler,” the agent cut in, his irritation plain.

“Right, listen, I couldn’t do the things you just suggested by tomorrow if I kept the staff working overnight.”

“You’re getting eighteen hours more notice than most people do, Dr. Auster.”

Stay calm, be courteous and professional at all times-his lawyer’s voice in his ear. “Be that as it may, sir, tomorrow presents real problems. My partner, Dr. Warren Shields, is out due to illness, and consequently I have an especially heavy patient load tomorrow. It would be a huge help if you could delay your search until after the weekend.”

Biegler cleared his throat. “Dr. Auster, perhaps this might be a good time to inform you that destroying medical records that are under subpoena constitutes obstruction of justice. In your case, those would be felony charges.”

Anger began to override the fear in Auster’s pounding heart. “Are you saying my records have already been subpoenaed?”

“That’s correct, sir. And I should inform you that digital files are no less a legal record than hard copies. If anyone attempts to erase any digital files, we will know it, and we will recover them. The penalties are quite severe.”

“I see.” Auster took a quick slug of vodka, then wiped his chin with the sleeve of his lab coat. “You know what I think, Agent Biegler? I don’t think you called me out of courtesy. I think you called to kick my blood pressure up. You called me to gloat. This is how you get your rocks off, isn’t it? You’ve got a bug up your ass about doctors, and you spend every day trying to bankrupt them or put them in jail. Well, I’ve got news for you. You’ve picked on the wrong doctor. First of all, I’m not guilty of anything. Second, I’ve got lawyers out the wazoo, and I can afford to pay them for a long, long time. And third…” Auster tried to remind himself that this conversation was almost certainly being recorded. It wouldn’t be good to threaten bodily harm or death by the intervention of third parties he might know in a questionable line of work. “Never mind about third,” he ended lamely. “You get the idea.”

“Yes, I do,” said Biegler. “You paint a vivid picture, Doctor. Now let me paint you one. You’re going to be indicted under a number of federal statutes, many of which have been newly created to deal with predatory physicians like you. You have violated the False Claims Act, the False Statements Act, several sections of the Social Security Act, and most importantly, the Kennedy-Kassebaum Health Insurance Portability Act. Also, by mailing fraudulent bills to patients in Louisiana, you’ve violated the Federal Mail and Wire Fraud Act, each instance punishable as a separate offense. Furthermore, there are civil penalties for all the above crimes. You have violated the Civil False Claims Act and the Civil Monetary Penalties Law…”

Auster was having difficulty breathing. The Diaka wasn’t going to do it this time. He opened a prescription bottle in his drawer and swallowed twenty milligrams of propranolol to slow his heart.

“Are you still there, Doctor?”

“Of course.”

“To sum up, under the new sentencing laws, you are facing the possibility of one hundred and seventy-five years in prison, and sixty-five million dollars in penalties. That doesn’t include punitive damages, which the government is entitled to pursue, up to three times the cost of actual damages. In each instance, of course.”

Auster felt a sharp pain radiating down his left arm. Even the hint of a heart event sent his pulse into the stratosphere.

“Dr. Auster?”

Auster shut his eyes and forced himself under control. All these sensations were simply a stress reaction. Paul Biegler had ambushed him, and the panic now redlining his vital signs was exactly the result Biegler had sought to produce. But he would not give the agent that victory. This was like tournament poker in Vegas. It was all about balls. Cojones. Nerves of steel. You might have bet heavy on the come and drawn a shit hand, but you couldn’t let anybody know that. Especially the guy sitting across the table from you, daring you to call. You knew he had the cards-you could read them in his eyes as surely as if his corneas were mirrors reflecting what was in his hand. But you had to call the bastard and play it out. Anybody could win with a royal flush. It was how you played the shit hands that proved your mettle.

“Did you hear what I said, Doctor?” Biegler repeated. “Sixty-five million dollars.”

Somehow, Auster found it within himself to chuckle. “That figure is a fantasy, Agent Biegler. None of that will ever happen. You know why? You’re rattling off all those numbers to scare me into settling out of court. You want me to pay Uncle Sam a big chunk of extortion money. Well, guess what? I have committed no crimes. None. And I already pay the government my fair share of extortion money. It’s called taxes, and I shell out close to a million dollars every year. So kiss my sanctified ass, you pencil-pushing cock-sucker.”

For a few glorious moments, Kyle Auster felt the euphoria of having done what every hardworking American wanted to do in his heart of hearts, tell the government to go to hell-and it felt good.

Then Agent Biegler started laughing. “You’re something, aren’t you?” he said, his voice betraying something like admiration. “I heard that about you. High-stakes gambler, they tell me. Boy, this one’s gonna be fun. By noon tomorrow, you’re going to think you’re dealing with a proctologist, not a Medicaid investigator.”

“What exactly are you, Agent Biegler? Are you really an investigator? Because I smell a lawyer. I can respect a cop, you know? But a lawyer’s something else again.”

“I have a law degree.”

“Couldn’t pass organic chemistry, huh?”

Biegler’s laughter stopped. “I should also inform you that as of nine a.m. tomorrow, all Medicaid payments to the partnership of Auster-Shields Medical Services will cease. You are being excluded from the Medicaid program pending the outcome of your criminal trial. Have a nice day, Doctor.”

Auster slammed down the phone before Biegler could hang up. “Vida!” he yelled at his door. “Vida!”

Nothing.

He buzzed the front. “Nell, tell Vida to come back here!”

“Yes, Doctor.”

Auster put away the Diaka bottle and took three deep breaths to try to calm down. A moment later, Vida stepped into his office, her face lined with worry.

“Nell told me who it was,” she said. “You shouldn’t have taken that call, Kyle.”

“Yeah, well, you should have been here to tell me not to take it.”

“Let me guess. You got into a pissing contest.”

Auster shrugged helplessly. “Do you know what he said I’m facing?”

“Jail, I guess.”

Auster leaned forward and looked hard into Vida’s heavily made-up eyes. “Not just jail. A hundred and seventy-five years in prison.”

She didn’t flinch. “No way. Never happen.”

“Then there’s the little matter of sixty-five million dollars in penalties.”

At last her face lost some color. “Sixty-five million? Can that be true?”

“Oh, yes. And that’s not counting punitive damages. You need to start researching the Kennedy-Kassebaum law. If you want to know what the rest of your life looks like, that is.”

Vida walked halfway around the desk and looked down at him. “Don’t let that asshole get to you. He’s just talking tough, like all cops do.”

“He’s pretty good at it.”

“It doesn’t matter. I’ve been sterilizing records for the past ten days. We never did anything stupid. I’ve been working in medical offices for eighteen years. Everything we billed for can be defended on medical grounds.”

“But the special patients…they can blow us out of the water. The stuff we did on them was based on total fiction.”

“Wrong. They said the words to you, Kyle. They made the complaints. You did what any conscientious physician would do, even if you thought the complaints might be psychosomatic.”

“Jesus, Vi.”

She reached out and brushed some hair from his eyes. “You’ve got to hold your nerve, baby.”

“We paid them to say that stuff!”

Vida shook her head. “Never happened. Untraceable cash, and long gone now, I promise you.”

“But if they testify-”

“They won’t. Where’s the upside for them? From us they get cash and free medical care. From the government they get jack shit. Anybody makes trouble, we’ll buy them off.”

“What if somebody has an attack of conscience?”

“They won’t. I didn’t pick a bunch of Holy Rollers to do this, I picked good, compromised Christians. The only thing we have to worry about is somebody you pissed off. Somebody testifying out of revenge. Like a woman, say.”

Auster’s mind flew back to a couple of attractive female patients, one of whom Biegler had called by name. In the natural course of things, they had offered him certain sexual favors in exchange for certain prescriptions, and he had not resisted as he should have. When their requests got out of hand, he’d had to cut them off, no matter what they offered. One or both of those women might present problems, particularly if the government had leverage over them based on drug-related charges.

“I see we’ve got a problem,” Vida said harshly. “Who is she?”

“Nobody. I was just going over it all in my mind.”

“Bullshit. Spill it, Kyle.”

Paul Biegler needed Vida working for him. She was relentless. Auster sighed heavily. “Quinesha Washington.”

Vida went pale. “That crackhead? You went with that skank?”

“Just a blow job-I never touched her otherwise.”

Vida shuddered in disgust. “Well, I hope it was a good one. She’s going to cost us plenty.”

A good one? More like a dozen good ones. “Sorry.”

“You go tell JaNel to draw blood for an HIV test.”

“Come on, Vi-”

“Now, damn it! You don’t have the sense God gave a tomcat.”

Auster held up his hands in surrender. “I’ll do it when we’re done.”

“We’re done until you get that test back. I’m going back up front to try to save you from yourself.” She turned on her heel and stormed out.

Auster leaned back in his chair and waited for his heart to slow. A few blistering images of Quinesha Washington on her knees before him arced through his brain, but they vanished as Paul Biegler’s threats came rushing back. The funny thing was, the patients and the records weren’t what really worried Auster. What worried him was his partner.

Taking on Warren Shields had been a mistake. Auster had assumed that Shields, like all the young docs, was hungry for money. And Warren certainly had nothing against making money. But he was constantly checking himself against a code of ethics that belonged to an older generation of doctors-hell, the generation behind Auster, even. It was maddening. On the other hand, the affluent patients in town loved the guy, so he was still good for business.

Then, like a gift from heaven, Shields had suddenly come around on the money issue. About a year ago, he’d walked into Auster’s private office after work and said point-blank that he needed to make more money. Auster told him it was no problem, that the money had always been there for the taking, had Warren been ready to earn it. Warren had just nodded and said he was, and that was that. Auster didn’t know what had precipitated Warren’s sudden venality-a mistress, a drug habit, an expensive hobby-nor did he care. In short order he’d put Vida in charge of Shields on a day-to-day basis. Before Warren checked the billing code after seeing a patient, Vida would ask him a few questions, then check the appropriate box herself. A busy physician like Shields didn’t have time to be bothered with trying to figure out the finer shades of what constituted a Level 5 exam.

Within a month, Shields’s income almost doubled.

That abrupt uptick in billing might have been what attracted the attention of the Medicaid Fraud Unit. But Auster knew why he’d pushed it. Warren Shields’s reputation was spotless; he was the last doctor anyone would suspect of padding his charges. And Shields truly resented government intervention in medicine. Auster had no doubt that, confronted by an accusing government lawyer, Warren would experience a primal burst of outrage. If that pencil pusher Biegler went after Shields, he would get a blast of righteous anger that would set him back on his heels. Then Shields would use his considerable medical knowledge to defend every bill for every patient he’d ever examined. Auster would do the same. And if Vida could really keep the special patients quiet…then everything would be all right.