The Personal Toll of Whistle-Blowing

Why one physician took the risk of becoming an F.B.I. informant to expose alleged Medicare fraud.





Healogics to Pay Up to $22.5M in False Claims Settlement

Image result for hyperbaric chamber

Whistleblower lawsuits had alleged that the Florida-based wound care specialist knowingly filed bogus claims to Medicare for services that weren’t needed.

Healogics, Inc. will pay up to $22.51 million to settle whistleblower allegations that billed Medicare for medically unnecessary and unreasonable hyperbaric oxygen therapy, the Department of Justice said.

Jacksonville, FL-based Healogics manages nearly 700 hospital-based wound care centers across the nation.

The settlement resolves allegations that from 2010 through 2015, Healogics knowingly submitted false claims to Medicare for medically unnecessary or unreasonable HBO therapy, DOJ said.

Healogics will pay $17.5 million, plus an additional $5 million if certain financial contingencies occur within the next five years, for a total potential payment of up to $22.51 million. The company has also has entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General.

“When greed is the primary factor in performing medically unnecessary health care procedures on Medicare beneficiaries, both patient well-being and taxpayer funds are compromised,” said HHS OIG Special Agent in Charge Shimon R. Richmond.

The settlement came as the result of whistleblower lawsuits filed by a former executive at Healogics, and a separate suit filed by two doctors and a former program director who worked at Healogics-affiliated wound care centers. The four whistleblowers are expected to share $4.2 million of the settlement.



Aetna whistle-blower put on leave after accusing CVS Caremark of $1B billing scheme

Image result for whistleblower lawsuit


Aenta’s former chief Medicare actuary was placed on administrative leave after filing a whistle-blower lawsuit alleging pharmacy benefits manager CVS Caremark overbilled Medicaid and Medicare for prescription drugs, according to The Columbus Dispatch.

Here are four things to know about the lawsuit.

1. Sarah Behnke, Aetna’s former chief Medicare actuary, filed the pending whistle-blower suit after her internal investigation found CVS Caremark has been allegedly overbilling the federal government for prescriptions since 2007, according to the lawsuit. Ms. Behnke accused CVS Caremark of inappropriately billing the government $1 billion-plus in fraudulent charges.

2. Aetna placed Ms. Behnke on administrative leave after the whistle-blower suit was unsealed in federal court in early April. The unsealing comes as CVS Health, the parent company of CVS Caremark, is attempting to buy Aetna for $69 billion.

3. Ms. Behnke’s lawyer told The Columbus Dispatch Aetna’s decision to place its then-Medicare actuary on administrative leave was “retaliatory and inappropriate.”

4. CVS Caremark rejected the allegations and said it will hand documents over to the court by June 1. The company said it was unaware who filed the lawsuit until after its parent put out an offer to Aetna. CVS Health spokesperson Michael DeAngelis told the publication, “We believe this complaint is without merit, and we intend to vigorously defend ourselves against these allegations.” Aetna officials declined The Columbus Dispatch‘s request for comment.


Banner Health settles whistleblower case for $18 million

Image result for Banner Health settles whistleblower case for $18 million


Banner Health has agreed to pay more than $18 million to settle whistleblower claims that the Phoenix-based health system admitted patients who could have been treated less expensively at outpatient facilities.

The settlement resolves a whistleblower case brought by a former Banner Health employee who claimed one dozen hospitals in Arizona and Colorado overcharged Medicare for brief, inpatient procedures that should have been billed on a less costly outpatient basis, the U.S. Attorney’s Office in Arizona said.

The settlement resolves allegations that Arizona’s largest health provider “inflated in reports to Medicare the number of hours for which patients received outpatient observation care during this time period,” according to a statement from the federal prosecutors.

The settlement involved Medicare billing at one dozen hospitals from November 2007 through December 2016.

The case was brought by former Banner Health employee Cecilia Guardiola under the federal False Claims Act, which allows individuals to bring lawsuits on behalf of the government and collect a portion of any settlement. Under terms of the settlement, Guardiola will be paid $3.3 million.

Banner Health said in a statement that the settlement does not include any findings of wrongdoing and allows the system to avoid the costs and disruption of ongoing litigation.

“Banner Health is fully committed to adhering to all legal and regulatory requirements and providing patients with the highest quality of care,” the statement read. “Although the rules that dictate when a hospital can accommodate a physician’s request to admit a Medicare patient are complex and evolving, our policy has always been to make those decisions in accordance with government guidelines.”

Guardiola, a registered nurse and a law school graduate, was hired by Banner Health in October 2012 as a director overseeing clinical documentation. She resigned three months later after she determined her efforts to bring “ethical compliance” would be ineffective, according to a statement issued by Kreindler & Associates, a law firm representing Guardiola.

During her brief stint at Banner, Guardiola evaluated Banner’s clinical documentation as well as short-stay inpatient claims.

She discovered that Banner hospitals billed an “inordinate and improper number of short-stay claims, particularly those for expensive cardiac procedures,” according to the statement.

In all, she discovered more than 650 examples of Banner billing Medicare for an inpatient claim even though the patient was admitted and discharged the same day, the statement said.

She also discovered that two hospitals, Banner Boswell and Banner Del Webb, identified some cardiac procedures as urgent rather than elective to prevent claims from being denied, the statement said.

Johns Hopkins favored out-of-state patients over locals to increase revenue, lawsuit claims

Image result for priority treatment


A former supervisor in the patient appointments department at the Johns Hopkins Health System Corp. has accused the medical system in a lawsuit of prioritizing out-of-state patients over Maryland residents to boost revenue.

Anthony C. Campos said in the lawsuit filed Wednesday in U.S. District Court that his department was directed with the task of “filling the plane” with patients from outside Maryland. The directive to bring in more of these patients came from the highest ranks at the medical system, the lawsuit contends.

In Maryland, hospitals are required under an agreement with the federal government to operate under global budgets assigned to them by the state that limit how much revenue they can make in a given year. The budgets were put in place as part of a broader effort to cut soaring health costs and improve care.

But the budgets only apply to patients who live in Maryland. Any money brought in by treating out-of-state patients is additional revenue for the hospital.

The lawsuit contends that Hopkins is violating a clause in its budget agreement with the state that says hospitals can’t deny services to patients for inappropriate financial reasons. The medical system is also required to provide care that focuses on the community, something the lawsuit contends can’t be done if the emphasis is on patients from elsewhere. The medical system also hid what it was doing from the Centers for Medicare and Medicaid, which oversees payments through public health programsand the Health Services Cost Review Commission, which sets the hospital’s global budgets, according to the lawsuit.

An attorney representing Campos said he was not available for comment.

“I think Maryland residents will find it highly offensive that Hopkins is pushing out-of-state residents to the front of the treatment line while Maryland residents are forced to the back of the line all in the interest of profits,” said the attorney, Lindsey Ann Thomas, with the law firm of Conti Fenn & Lawrence LLC.

In a statement Wednesday night, Johns Hopkins said the “the complaint is without merit. Safe and high quality care for all patients, regardless of where they live, is our number one priority. Our census shows that the majority of our patients are from Maryland and that the number has steadily increased over the past several years.” ​

The medical institution began pushing for more out-of-state patients in 2015, Campos said in the lawsuit. He pushed back and told his bosses his team was getting complaints and concerns from doctors about the preference being given to out-of-state patients. Campos’ supervisors responded that they were following the orders of senior management, according to the lawsuit.

Priority was sometimes given without taking into consideration which patients were sicker, the lawsuit said.

The tactics to attract these patients became more aggressive over time, the lawsuit said. Johns Hopkins USA, a medical concierge service, was enlisted to help prioritize out-of-state appointments. The medical system began targeting the most profitable departments, including neurosurgery, oncology, otolaryngology, pediatrics and surgery. In some departments, a supervisor was ordered to intervene if an out-of-state patient could not get an appointment within 30 days, and those patients were also given priority on wait lists, the lawsuit said.

In May 2016, the Department of Patient Access was told that 250 to 350 additional out-of-state cases were needed that fiscal year to reach profit targets of $5 million to $7 million, according to the suit.

Campos is asking that the government be awarded damages and Johns Hopkins fined under the False Claims Act. He is also asking for a “percentage of any recovery allowed to him.”

69 Indiana hospitals accused of retaining $324M in fraudulent EHR incentive payments

Image result for false claims act

A recently unsealed lawsuit filed by attorneys under the qui tam, or whistle-blower, provision of the False Claims Act accuses Indiana hospitals of overcharging patients for their electronic medical records.

Here are eight things to know about the lawsuit.

1. After experiencing difficulty obtaining medical records from four Indiana hospitals in their work on personal injury and medical malpractice cases, attorneys from Anderson, Agostino & Keller sued the hospitals in September 2016. They alleged the hospitals falsely certified they were meaningful users of EHR technology.

2. Under meaningful use stage 1, hospitals could show compliance and receive incentive payments by filing attestation documents reporting compliance with core criteria requirements. The lawsuit against the Indiana hospitals focuses on core measure No. 11, which aimed to provide patients with electronic medical records within three business days of receiving a request from the patient or their agent.

3. To receive the incentive payments, hospitals had to show the number of medical record requests they received annually and if the records were supplied to those requesting them within three business days. Hospitals that failed to meet at least 50 percent of their requests within the time frame would not be eligible to receive incentive payments.

4. Based on their experience requesting records from the hospitals and after examining public disclosures, the lawyers alleged the hospital defendants falsely certified compliance with core measure No. 11.

5. The lawyers also claim the hospitals allowed CIOX Health, a company that provided medical records for the hospitals, to illegally profit from the release of the electronic medical records.

“CIOX routinely and repeatedly engaged in a practice, policy, and/or scheme to illegally and fraudulently over-bill patients for the provision of medical records,” the complaint states.

6. The lawyers added organizations operating an additional 65 hospitals to the lawsuit after examining disclosures and identifying a statistical trend that they argue indicates the same type of fraudulent reporting of core measure No. 11.

7. “In sum, these hospitals have been paid $324,386,169.32 in public funding from the citizens of the United States in return for the promise that patients would be provided with fast, cheap, easy access to their electronic health records, and these hospitals have failed to keep that promise,” the complaint states.

“A failure to properly track and report core measure 11 means that the defendant hospitals did not achieve ‘meaningful use’ as defined by the legislation and its ensuing rules. This means that they were not eligible to receive any funding under this program, and have sought and received the grant funding at issue in a fraudulent manner that constitute false claims for public funding.”

8. The Department of Justice declined to intervene in the lawsuit.

Lawsuit: Epic’s software double-bills Medicare, Medicaid for anesthesia services

Image result for false claims act

Health IT giant Verona, Wis.-based Epic Systems has been hit with a False Claims Act lawsuit that alleges the company’s software double-bills Medicare and Medicaid for anesthesia services, resulting in the government being overbilled by hundreds of millions of dollars.

The lawsuit, which was filed under the qui tam provision of the False Claims Act in 2015 and made public Thursday, alleges Epic’s billing software’s default protocol is to charge for both the applicable base units for anesthesia provided on a procedure and the actual time taken for the procedure. This results in the provider being reimbursed twice for the base unit component, according to the lawsuit.

The whistle-blower who filed the lawsuit, Geraldine Petrowski, worked at Raleigh, N.C.-based WakeMed Health from September 2008 through June 2014. In her role as supervisor of physician’s coding, Ms. Petrowski served as the hospital liaison for Epic’s implementation of its software at WakeMed Health.

Ms. Petrowski claims she provided examples to Epic representatives illustrating the double-billing practice, and the company initially ignored her complaints. “It was only after relator, Petrowski, reiterated her direction to fix this software setting that [Epic] relented and fixed it only for the WakeMed Health facility,” according to the lawsuit.

The lawsuit alleges the unlawful billing protocol has resulted “in the presentation of hundreds of millions of dollars in fraudulent bills for anesthesia services being submitted to Medicare and Medicaid as false claims.”

In a statement to Healthcare IT News, an Epic spokeswoman said, “The plaintiff’s assertions represent a fundamental misunderstanding of how claims software works.”

The Department of Justice declined to intervene in the case, and the whistle-blower will move forward in the case without the government.