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.