On the streets of Managua, the shuttle bus wrapped in a giant ad for free health care stood out. “Medicare for people living abroad,” it proclaimed above the image of a cheerful older woman playing golf. But Medicare, the American public health insurance program for the elderly and disabled, isn’t available in Nicaragua or anywhere outside the U.S., except in emergency circumstances. The clinic advertised, Nostrum Medical Center, had a way around that: Patients were required to provide a U.S. address, so their visits could be billed to American taxpayers.
Before the Nicaraguan scheme and a related one in the Dominican Republic were shut down last fall, the U.S. government paid out $25 million from 2011 to 2014 for medical care received by more than 1,000 foreign residents who signed up using post office boxes, mail-forwarding services, or the addresses of friends or relatives in Florida to conceal that they lived overseas. “We were a little bit astonished by the brazenness of the conspirators in this case, particularly with their widespread and open marketing,” says Shimon Richmond, the special agent in charge of the Miami regional office of the inspector general of the U.S. Department of Health and Human Services (HHS), which oversaw the investigation.