Blowing the Whistle Laws protect nurses who report healthcare fraud |
Someone who makes unauthorized public disclosure of wrongdoing. Is whistle-blower a bad word? You decide. In a 1996 report, the U.S. Department of Justice called healthcare fraud the crime of the ’90s. Since then, recovery of money spent on erroneous and fraudulent claims has become a top priority for federal and state governments.  Look at the numbers: In 1998, the federal government spent $217 billion on Medicare. The Health Care Financing Administration reports about $22.5 billion went to California beneficiaries in 1999 and $14.7 billion to Texas. The agency estimates a Medicare billing error rate of 7 percent to 8 percent, with errors comprised of legitimate mistakes as well as fraudulent claims.Medicaid, jointly funded by federal and state money, could have an even higher error rate. Federal contributions to Medicaid totaled $171 billion in 1998. Texas spends about $10 billion each year on its Medicaid program. California, which calls its program Medi-Cal, spends about $20 billion annually.”While it’s difficult to determine Medi-Cal fraud, the standard estimate is up to 10 percent of total annual expenditures,” said Collin Wong, executive director of the California Attorney General’s Bureau of Medi-Cal Fraud. This amounts to about $2 billion for California and $1 billion for Texas.Aggressive enforcementThe federal government strengthened its existing False Claims Act to provide additional funding for fraud investigations and to reward whistle-blowers with a percentage of recovered funds. Since 1996, aggressive enforcement of the legislation has recovered an estimated $1.9 billion. Millions of dollars also have been awarded to whistle-blowers. HCFA offers pamphlets to Medicare beneficiaries that provide information on recognizing and fighting fraud.States are beefing up anti-fraud regulations, too. The Texas Attorney General’s office joined forces with the Texas Health and Human Services Commission to detect and prevent fraud and abuse of Medicaid.”Last year, Texas passed a state version of the False Claims Act in an effort to combat healthcare fraud,” said Marlene Martin, a lawyer who represents whistle-blowers. “The law imposes heavy penalties for fraudulent billing practices for the state portions of Medicaid money.”Financial rewards to whistle-blowers are part of the new provisions.”California has its own stand-alone False Claims Act similar to the federal version,” Wong said. Sacramento is home to a joint task force comprised of FBI agents and members of the U.S. Attorney General’s Office. The team’s investigation and prosecution of fraud is one of the most effective programs in the nation. Of the 250 cases now under investigation, most focus on pharmacists and medical equipment suppliers. The task force also has targeted several state employees, including one charged with accepting bribes from physicians to expedite Medi-Cal provider numbers.Protecting employees, patients“Nurses are on the front lines. They have an excellent vantage point to get a global picture of what’s happening,” Martin said. Whether it’s unsafe patient care or financial fraud, most states have enacted whistle-blower laws that protect nurses, patients and other healthcare professionals from retaliatory action.The Texas Nurses Association pushed for whistle-blower protection in a 1987 addition to the Nursing Practice Act. Two years ago, the Texas Supreme Court upheld and strengthened the legislation. Stephanie Tabone, RN, director of nursing practice for the association, has firsthand experience with blowing the whistle.”Years ago, I reported fraudulent billing practices and financial kickbacks for medical equipment. Someone broke into my files and stole the records, leaving me without adequate proof to move forward on the case.”Now, she offers this advice to nurses who are thinking about reporting fraud: “Nurses are generally people with a high ‘justice meter.’ They want to see the right thing done right now. If you’re thinking about doing something like this, go about it systematically, don’t be conspicuous, keep detailed records, and seek the appropriate authority.”Donne Brownsey, JD, lobbyist for the California Nurses Association, is proud of the organization’s sponsorship of a whistle-blower law last year.”The law protects nurses and employees, as well as patients,” Brownsey said. “It shifts the burden of proof to the facility. Anyone thinking about whistle-blowing should keep really good records, especially about what led up to the retaliatory actions. The nurse will need to show he or she acted appropriately. Even though the law provides additional protection, these are very difficult cases.”Martin said, “Whistle-blowing can be heart-wrenching, often resulting in retaliation, termination and being ostracized by co-workers. The typical whistle-blower is a principled individual committed to doing the right thing. Many have told me the reward money is small compensation for what they and their families had to go through.”Unscrupulous providers are getting the message, too: It’s not acceptable to steal money that’s intended for the care of the oldest, poorest and most fragile. | |
| The Dirty DozenSome examples of fraud in health care:Billing for nonexistent or deceased patients.Billing for services not provided.Billing for new medical equipment that is used.Billing for unnecessary treatment or testing.Billing for physician services that are provided by unlicensed personnel.Inflating billing for services that are covered.Paying kickbacks for referrals.Concealing ownership (i.e., physicians referring patients to companies they own).Unbundling – billing separately for services that should be included in one fee.Upcoding – altering billing codes to reflect more expensive services.Waiving required co-payments and deductibles.Practicing direct solicitation of patients.~ Connie Goldsmith | |
