The Opioid Connection

The Department of Justice has called pain management clinics "ground zero" for healthcare fraud. Between opioid overprescription, unnecessary procedures, and high-volume anesthesia billing, pain clinics have been at the center of some of the largest Medicare fraud prosecutions in history. Now our AI model has flagged 7 pain management providers whose billing patterns match convicted fraudsters — collectively billing $10.4M to Medicare with 186.4K services.

Why Pain Management Is a Fraud Hotspot

Pain management sits at the intersection of several factors that make it uniquely vulnerable to fraud:

• Subjective diagnosis: Pain is self-reported and difficult to objectively measure, making it easy to justify treatments that may not be necessary
• High-reimbursement procedures: Interventional pain procedures (epidural injections, nerve blocks, spinal cord stimulators) command high Medicare reimbursement rates
• Repeat visits: Chronic pain requires ongoing treatment, creating a built-in justification for high-volume billing
• Anesthesia codes: Pain management frequently involves anesthesia services, which use time-based billing that's notoriously difficult to audit
• Opioid connection: The same clinics prescribing opioids are performing procedures — creating dual revenue streams and patient dependency

John Hunt: $3.06 Million and 64,000 Services

Hunt's numbers are staggering. At 64.3K total services, he performed more services than most entire pain clinics. His 4.53 services-per-beneficiary ratio — meaning each patient received an average of 4.53 services — is well above the pain management specialty norm and indicates either extraordinarily complex patients or aggressive treatment patterns.

Florida is no coincidence. The state has long been the epicenter of pain clinic fraud, earning the nickname "Pill Mill Capital of America" during the peak of the opioid crisis. While Florida has since tightened regulations, our data suggests that high-volume billing patterns persist — they've just shifted from opioid prescriptions to interventional procedures.

The Florida Double: Hunt and Ali

Two of the seven flagged pain management providers practice in Florida. Danish Ali, also Florida-based, billed $2.0M with a 3.10x markup ratio — meaning he charged Medicare 3.1 times what it actually paid. Between Hunt and Ali alone, Florida pain management accounts for $5.1M in flagged billing.

Ali's markup ratio is particularly notable. While Hunt's pattern is volume-driven (massive service counts), Ali's pattern suggests aggressive charge inflation — billing Medicare far more than the service is worth and collecting whatever percentage CMS approves. These represent two distinct fraud archetypes operating in the same specialty and state.

Joseph Oei: Texas Pain and $1.81M

Oei, a Texas-based pain management provider, ranks #176 with the highest fraud probability among the pain management flagged group at 90.8%. His 2.77x markup ratio and25.7K services across 8.7K beneficiaries paint a picture of a high-volume practice with elevated billing patterns.

Texas is the second-largest state for Medicare spending and has seen significant DOJ enforcement action against pain clinics. In 2023 alone, the DOJ's Houston office prosecuted multiple pain management fraud cases involving unnecessary procedures and kickback schemes.

All 7 Flagged Pain Management Providers

The Extreme Markup Problem

Two providers — Kevin Fitzgerald (MI) and Theron Grover (MI) — show "Extreme markup" as a risk factor. Their markup ratios of 3.68x and 3.59x respectively mean they're charging Medicare roughly 3.5 times what CMS actually reimburses. While providers are free to set their own charges, extreme markups serve a strategic purpose in fraud: by inflating charges, providers ensure maximum reimbursement even after CMS applies its fee schedule limits.

Both Michigan providers operating with extreme markups suggest a possible regional pattern. Michigan has faced its own pain management enforcement challenges, with multiple DOJ cases targeting unnecessary procedures and anesthesia billing fraud.

The Opioid Crisis Connection

The opioid epidemic and Medicare pain management fraud are deeply intertwined. The same business model that fueled the pill mill crisis — high-volume patient throughput, repeat visits, and maximized billing per encounter — has simply evolved. Instead of prescribing opioids (now under intense DEA scrutiny), many pain clinics have shifted to:

• Epidural steroid injections: High-reimbursement procedures that can be repeated frequently with minimal clinical justification required
• Facet joint injections: Multiple bilateral injections billed separately, turning a single visit into 4-8 line items
• Nerve blocks: Diagnostic and therapeutic blocks that can be performed in-office with anesthesia charges
• Urine drug testing: Mandatory testing for pain patients creates an ancillary revenue stream — some clinics bill $1,000+ per test
• Spinal cord stimulators: Devices costing $30,000-$50,000 with implantation fees, creating enormous per-patient revenue

The Anesthesia Billing Problem

Pain management intersects heavily with anesthesia billing — one of the most fraud-prone areas in Medicare. As we covered in our anesthesia markup investigation, anesthesia uses time-based billing codes that are inherently difficult to audit. A provider can bill for 30 minutes or 90 minutes of anesthesia, and there's often no independent verification of the actual time spent.

Interventional pain management providers like John Hunt frequently bill both the procedure and the anesthesia — collecting two revenue streams from a single patient encounter. When combined with high patient volume, this creates billing levels that our model flags as matching convicted fraudster patterns.

Geographic Patterns

The geographic distribution of flagged pain management providers is not random:

Florida and Michigan each have two flagged providers, but Florida's combined billing ($5.1M) is more than 2.5x Michigan's. Every flagged state has a documented history of DOJ pain management enforcement — our model is finding patterns in exactly the places you'd expect.

What Makes Pain Management Different

Compared to the internal medicine fraud patterns that dominate our model (53% of all flagged providers), pain management fraud has distinct characteristics:

• Higher per-provider billing: Pain management averages $1.5M vs ~$750K for flagged internal medicine
• Higher markups: Average 3.0x vs 2.3x for internal medicine — reflecting expensive procedural billing
• Procedure-driven: While IM fraud tends to be office visit volume, pain management fraud revolves around high-reimbursement procedures
• Equipment and implants: Spinal cord stimulators and other devices add billing layers that don't exist in primary care fraud

The Bottom Line

Pain management fraud isn't new — the DOJ has been prosecuting it for decades. What's new is the ability to detect it algorithmically. Our model, trained on thousands of confirmed fraudsters, has identified 7 pain management providers whose billing patterns are statistically indistinguishable from convicted criminals. Combined, they've billed Medicare $10.4M while performing 186.4K services.

The opioid crisis may have shifted from pills to procedures, but the underlying economics remain the same: pain is subjective, patients are desperate, and Medicare pays the bills. Until CMS develops specialty-specific fraud detection for pain management — accounting for the unique billing patterns of procedural pain clinics — providers like these will continue to operate in the gap between what the data shows and what enforcement catches.