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Curbside Consult with Dr. Jayne 8/7/23

August 7, 2023 Dr. Jayne 2 Comments

I will never stop being amazed at the stories of physicians and others who believe they can commit healthcare fraud and get away with it. Especially with the use of computerized systems for billing, inventory management, and more, it’s harder to avoid creating a trail than it might have been back in the paper era.

One of my former residency colleagues sent an article this week about a physician who we knew during our time in training. He was arrested after federal healthcare fraud charges were filed against him. The physician and his office manager are accused of conspiring to bill for services that he didn’t perform or supervise, and which sometimes occurred on dates of service when he wasn’t even in town or even in the country.

They also took advantage of physicians who were still going through training, which makes the whole enterprise even more offensive. Attending physicians were lured into signing bogus collaborative practice agreements, saying that they would supervise the physician learners when they didn’t meet the stipulations of the program criteria. Learners were promised a leg up in the process of trying to obtain a residency training position in the US, but received little education or supervision while being expected to deliver clinical care that possibly exceeded their capabilities or provisional licensure.

For those of us who were aware of the business activities of the accused, it’s particularly salacious, because he made inflammatory statements about competing healthcare organizations, talking about his practice’s superiority for caring for large numbers of Medicaid patients and doing a better job supporting the needs of the community than other similar organizations. Looking at the timeline of the alleged charges, he was likely committing Medicaid fraud at the exact same time he was bragging about his participation in the program.

Electronic health records and their associated billing systems store vast amounts of metadata about the documentation created on their systems. You have to be fairly knowledgeable about database structure and the creation of metadata to try to alter the information, and I suspect that the alleged perpetrators of this scheme weren’t that smart. They certainly wouldn’t have had the ability to alter airline reservations, hotel bills, or other travel records that would demonstrate the whereabouts of the physician at times that he was supposed to have been rendering care or supervising learners.

Unfortunately, it’s not only physicians that are behaving badly at times. Earlier this summer, The Kraft Heinz Company and its various employee and retiree benefits organizations sued Aetna over its failure to provide all of the company’s medical claims data for review. Kraft Heinz is a self-funded employer that uses Aetna as its third-party administrator for medical claims. As such, it has the need to ensure benefits are maximized for plan participants and that costs are managed appropriately.

The Consolidated Appropriations Act of 2021 gives employers greater access to claims data for monitoring. Kraft Heinz claims that Aetna is limiting its access to its own claims data, preventing it from ensuring that the plan’s assets are being managed properly. Specifically, Kraft Heinz is looking into data around provider payments, prior authorizations, and coverage dates. The company alleges that the insurer “paid millions of dollars in provider claims that never should have been paid, wrongfully retained millions of dollars in undisclosed fees, and engaged in claims-processing related misconduct to the detriment of Kraft Heinz.”

I’m sure there are plenty of payer and claims data experts who are ready to dig into the matter, which also includes an accusation that Aetna refused to provide the requested data in a standardized format. Other self-funded organizations, including Bricklayers and Allied Craftworkers Local 1 Fund and Sheet Metal Workers Local 40 Fund are also suing their third-party administrators for lack of access to claims data. It will be interesting to see how the proceedings unfold over the coming months and whether other self-funded plans join the effort to force more transparency from their vendors to ensure that employees and retirees are receiving the healthcare services they’re entitled to.

Rounding out the trifecta of entities behaving badly are health systems and contracted provider organizations. Two North Carolina-based physicians sued HCA Healthcare and TeamHealth in 2022, with the documents becoming unsealed earlier this year when federal regulators passed on becoming involved. The physicians were originally employed at Mission Hospital System, which became part of HCA in 2019. TeamHealth took over physician staffing at the facility the following year. The physicians claim that following the transition, employees were encouraged to order duplicative services, including laboratory testing and imaging studies, especially when patients were received in transfer from outside facilities. They claim that management encouraged them to use generic protocols called “powerplans” rather than their clinical judgment, resulting in excess testing and diagnostic services. They further allege that physicians were pressured to see as many patients per shift as possible regardless of potential negative impact on patients.

The physicians attempted to engage the federal government by serving as whistleblowers under the premise that the organizations were committing fraud by overcharging government programs for medical services. In addition to the redundant services, they also allege that staff overused trauma alerts and the practice of calling codes in the emergency department as a way to generate additional billings. One such example was a trauma designation given to a stable injured patient who was received in transfer and who had already received extensive imaging procedures. The plaintiffs also cited language in emergency department administrative documents that treated physicians more like “salesmen” rather than “emergency department medical professionals who are there to provide care for patients.”

Of course, there were also stories in the last month about an EHR vendor accused by the DOJ of gaming the certification process, along with another EHR vendor accused of stealing intellectual property from both a client and a third-party content vendor. It just goes to show that there’s never a dull moment in healthcare, and that regardless of the altruism of many of us in the field, there will always be someone looking for a way to make a profit at the expense of patients, workers, or taxpayers. Stories like these certainly remind us that depending on how long we’ve been in practice or in the healthcare IT universe, this isn’t necessarily the healthcare world that we all signed up for.

What do you think about the state of healthcare fraud, and would you ever serve as a whistleblower? Leave a comment or email me.

Email Dr. Jayne.



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Currently there are "2 comments" on this Article:

  1. I agree. I am a whistleblower for an FQHC where the CEO was taking the federal funds and using it for her own personal luxury items – house in Florida, new boats, cars, etc. Hired her husband who owned his own business, gave him a title, paid him just under $100k but he never worked there. I worked with OIG, FBI and IRS along with the GA Medical Composite board b/c there was opioid abuse as well. I met with FBI, IRS in the morning providing all the paperwork to them. She was removed from her position later that afternoon. The problem is that so many people looked the other way. I was retaliated against at first, but I’d do it all over again if I had to.

  2. “… would you ever serve as a whistleblower?”

    Yes. Reluctantly, but yes. It’s a moral imperative aside from any legal obligations.

    However being a whistleblower carries a lot of risk, there’s no real payoff for taking the risk, and frankly? Most organizations don’t like whistleblowers. Even if they eventually do the right thing.

    Whistleblowing implies a management that (at best) wasn’t doing their job. At worst, management was 100% in on the wrongdoing. It’s a black eye for the organization to have a successful whistleblowing campaign.

    The whistleblower themselves shows “too much” independence. They are “insufficiently obedient”, and “do not respect” management. A whistleblower can easily be portrayed as defiant, a rogue operator, and a problem employee.

    Don’t kid yourself. Whistleblowing is a hard road to take.

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