In “Recovery Inc.,” reporters at KARE 11 in Minneapolis revealed widespread evidence of fraud in Minnesota’s addiction recovery industry, exposing how companies billed taxpayers for services never rendered. The investigation began with tips about dubious billing practices and expanded to uncover systemic issues in government oversight and accountability. A key case involved a double murder where the accused did not receive treatment as claimed by the facility. KARE 11’s reporting highlighted egregious examples, such as billing Medicaid for 203 hours of work by a single employee in one day and charging for movie nights as therapy sessions. The series uncovered a relationship between Kyros, a for-profit entity, and Refocus Recovery, a nonprofit, both founded by Daniel Larson. The investigation showed that Refocus funneled 96% of its taxpayer revenue to Kyros, based on exploiting Medicaid billing practices.
KARE 11’s dedicated journalism, often conducted under threats, exposed these practices by interviewing affected individuals and deciphering complex billing data. Their reporting prompted multiple federal and state investigations, including an FBI raid, a Department of Justice asset freeze, and a criminal indictment. The exposé also led to significant leadership changes, with top executives resigning. Furthermore, the investigation inspired swift legislative reform, passing laws to improve supervision, audit Medicaid billing, and eliminate nonprofits with conflicting interests. The series’ ripple effect included bipartisan legislative hearings, and KARE 11’s courage in challenging an unconstitutional gag order fortified its impact, emphasizing the media’s critical watchdog role in society.
Illustration courtesy of KARE-TV.
Medicare Inc.: How Giant Insurers Make Billions Off Seniors
The Wall Street Journal’s investigative series “Medicare Inc.: How Giant Insurers Make Billions Off Seniors” exposed how private insurers exploit the Medicare Advantage system by prioritizing profits over actual patient care. The series, led by a team with extensive experience in analyzing Medicare data, revealed that insurers are financially incentivized to minimize services while increasing reported diagnoses to boost government payments. The investigation involved unprecedented access to Medicare data, covering every service provided to beneficiaries from 2015 to 2022. Through data analysis, interviews and internal corporate documents, the team discovered a disturbing pattern where insurers profited from diagnoses reported without providing corresponding treatment, including during home visits.
The Journal’s in-depth research, which included reverse-engineering Medicare’s payment algorithms, confronted numerous challenges, including learning complex statistical software and processing massive datasets. Their findings uncovered systemic issues, such as insurers exploiting home visit diagnoses to claim billions in inflated payments.
The impact of the investigation has been significant, prompting congressional inquiries and influencing federal policy. The Office of Inspector General recommended halting payments based solely on home visit diagnoses. The Congressional Budget Office estimated a potential $124 billion in savings over ten years if such payments were stopped. Additionally, federal investigations have been initiated, including by the Justice Department and Sen. Chuck Grassley, who cited the reports in demanding disclosures from UnitedHealth. The series has also galvanized further research, with institutions like the Kaiser Family Foundation expanding on the Journal’s findings about end-of-life care patterns. The Journal’s reporting is prompting legislative reforms and encouraging more accountability in Medicare Advantage practices.
Chart image courtesy of the Wall Street Journal.
She Ate a Poppy Seed Salad Before Giving Birth. Then They Took Her Baby Away.
This investigative series, spearheaded by reporter Shoshana Walter, uncovered the troubling practice of hospitals nationwide using unreliable drug tests on birthing patients, leading to unwarranted child welfare interventions. The investigation began when Walter heard from a mother whose positive methamphetamine test was falsely triggered by a common blood pressure medication. Further investigation revealed numerous cases, including Susan Horton, whose consumption of a poppy seed salad caused a false positive opiate test, resulting in her newborn’s removal. The reporting highlighted the high false positive rates of urine screens and the consequent threats many new mothers face from child welfare agencies.
Walter interviewed hundreds of women, examined medical records, and filed public records requests to scrutinize drug testing and reporting practices. Her findings exposed that federal authorities have long known about the unreliability of urine screens, yet no state safeguards birthing patients’ rights. This led to traumatizing experiences for many families who were wrongfully accused and separated.
The impact has been profound, with many affected women coming forward and advocacy groups mobilizing for change. The stories galvanized legislative attention, prompting U.S. lawmakers to condemn the practice and seek solutions. Civil rights organizations are leveraging the investigation to instigate legal and policy reforms across more than 20 states. Within the medical and child welfare communities, the series sparked discussions and initiated efforts to revise existing procedures, demonstrating the potential for systemic change prompted by rigorous investigative journalism.
Photo credit: Marissa Leshnov for The Marshall Project, used here courtesy of The Marshall Project
Overpayment Outrage
Each year the Social Security Administration issues billions of dollars in overpayments to recipients whose income or other qualifying criteria have changed, or as the result of agency miscalculations. Under federal law, the Social Security Administration is required to demand repayment of this money, treating it as debts to the federal government. These “clawbacks” can happen even decades after the initial overpayments occurred and even when they resulted from an agency mistake. In “Overpayment Outrage,” a collaboration that spanned a national nonprofit newsroom (KFF Health News) and Cox Media Group, a network of local TV news stations and their investigative and Washington, D.C. bureaus, the teamdug into the overpayment issue and the impacts of clawbacks on vulnerable people. They found that overpayments happen due to chronic understaffing at SSA, systemic delays in data tracking, and a process that made income changes and eligibility criteria invisible to those who were determining whether to issue a clawback demand. The reporting lays out potential solutions to address the legislative, funding, and process failures that cause this systemic problem. It reveals how Congress has demanded action to reduce excessive Social Security spending without adequately funding the agency that administers it, and examines the layers of complex policy, regulation, and procedural rules that employees and recipients of social security have to navigate to make the system work. The collaborative nature of the project and its publication in both print and TV outlets helped elevate the reach and impacts of the project.
For this impressive untangling of the root causes of problems in the functioning of government and the implementation of public policy, and explaining how this problem both impacted individuals and was not directly caused by them, “Overpayment Outrage” is the winner of the Goldsmith Awards’ inaugural Special Citation for Reporting on Government.
The Goldsmith Special Citation for Reporting on Government is intended to honor explanatory and/or investigative reporting that focuses on the functioning of government and the implementation of public policy. It aims to lift up reporting that illuminates the nitty gritty of governing – the people, systems, structures, and policies that layer together to make a government work, and, when it doesn’t, understanding why. The teams from Cox Media Group and KFF Health News are deserving of this special citation for their reporting on “Overpayment Outrage” because of the lengths they went to understand why failures happened, the impacts those failures have on individuals and communities, and the solutions suggested by their reporting – many of which were already being implemented in the weeks and months after the story came to light.
Denied by AI: How big insurers use algorithms to cut off care for Medicare Advantage patients
Following a tip from an employee at a small nursing home, STAT reporters Casey Ross and Bob Herman relied on internal sources, confidential company documents, and court records to reveal how UnitedHealth Group, the nation’s largest health insurer, was inappropriately using predictions from a flawed computer algorithm to deny care to seriously ill patients. Reducing older adults and people with disabilities to numbers, insurers used the predictions to deny or prematurely cut off rehab care of sick and injured Medicare Advantage beneficiaries and maximize the company’s profits. The publication of this four-part investigative series prompted federal regulators to issue new rules and launch their own investigations and triggered at least two class-action lawsuits.
With Every Breath: Millions of Breathing Machines. One Dangerous Defect.
After months of sorting through thousands of complaints submitted to the FDA, reporters revealed that Philips Respironics kept millions of dangerous breathing machines – used by COVID-19 patients, infants, the elderly, and veterans – on the market, despite warnings from their own experts that the devices posed serious health risks. The investigation also revealed that the FDA had received warnings about contaminants in the machines for years but repeatedly failed to warn the public. Their reporting prompted the Government Accountability Office (GAO) to launch an investigation of the FDA’s oversight of medical devices for the first time in a decade and led to calls by influential members of Congress for the Justice Department to open a criminal investigation into Philips Respironics.
Unresponsive
In this months-long investigation into Sedwick County EMS – the lone ambulance provider for more than half a million people – reporters at The Wichita Eagle uncovered a public safety crisis that put an entire community at risk. Through open records, leaked documents, interviews, and direct research, the reporters built a database of response times, and direct testimony to back it up, that showed the department had dangerously slow response times and staffing shortages driven by mismanagement. While under the EMS director’s leadership, the department had fallen from one of the best in the Midwest to one that showed up late for over 11,000 potentially fatal emergency calls in two years. The series led to the prompt ousting of the EMS director, an apology by the county manager for his slow response to the crisis, and most importantly – a massive overhaul of the county’s EMS service.
In reporting “Pain and Profit” the Dallas Morning News found that thousands of sick and disabled Texans were being denied life-sustaining drugs and treatments by the private health insurance companies hired by the state to manage their care. While these private contractors made billions of dollars from the corporate management of taxpayer-funded Medicaid, some of the most vulnerable Texans were denied critical services, equipment and treatments, often with profoundly life-altering results. As a result of the investigation the Texas legislature pledged millions of dollars to more closely regulate the system, monitor instances of denials of care, and reform the appeals process.
Learn more about how McSwane, Chavez, and the Dallas Morning News team found, investigated, and reported the story in a “how they did it” piece in The Journalist’s Resource, and a podcast interview with the reporters.
Rezulin: A Billion-Dollar Killer
An exposé of seven unsafe prescription drugs that had been approved by the Food and Drug Administration, and an analysis of the policy reforms that had reduced the agency’s effectiveness.
Doing Harm: Research on the Mentally Ill
A four-part series by Robert Whitaker and Dolores Kong shed light on the abusive research parameters of non-therapeutic experiments conducted on mentally incapacitated individuals. They focused on several victims who had suffered and were harmed by experiments that violated medical ethics standards.
