The corporatization of healthcare has played a significant role in creating an ethically compromised medical system. It is now common for hospitals to be part of, or affiliated with, large corporations, and the race to achieve greater profits is ever-present.
Some hospitals manage this balance well, but in others the pressure leads from cutting corners on patient care to submitting false invoices to the government or insurance companies. Eventually, this pressure can devolve into an institutional willingness to do whatever is necessary to increase revenue, at the expense of both patients and taxpayers.
It’s understandable how these problems become systemic. Hospital employees want to keep their jobs and may implicitly trust the organizations they work for. When employees do notice wrongdoing, they may be actively discouraged from speaking up. It can be difficult to know if or when to step in. For many healthcare providers, the tipping point is seeing patients not getting the care they deserve.
Fraud in hospitals is a growing problem, but it can be stopped with the vigilance and integrity of healthcare providers and administrators. The first step is to develop an awareness of the existing landscape, so that you know which problems a hospital might face.
Here are a few of the major fraud schemes that hospitals and healthcare providers have become involved with.
The Healogics Way
Many surgical procedures prompt high Medicare, Medicaid and TRICARE reimbursements, which makes them frequent targets for federal healthcare fraud. Patients undergoing or facing surgery can be especially vulnerable, and unfortunately some hospitals and healthcare providers have taken advantage of this.
In January 2016, The Whistleblower Attorneys filed a qui tam lawsuit against Healogics, Inc. on behalf of three whistleblowers. Healogics is the largest wound care operator in the country.
The lawsuit accuses Healogics of False Claims Act (FCA) violations centered primarily on a corporate strategy called the “Healogics Way.” According to the allegations, the Healogics Way is to subject patients to unnecessary medical procedures in order to increase federal reimbursements. Healthcare providers who worked at hospitals partnered with Healogics were allegedly fired for refusing to participate in this scheme. The most common procedure noted in the lawsuit was surgical debridement, which clears damaged tissue or other debris from wounds. For many patients, debridements have to be performed on a regular basis to keep the wound clean.
There are several debridement methods, some more costly and extensive than others. Healogics allegedly advised doctors to bill federal healthcare programs and insurers for the most costly procedures, regardless of the procedure that was actually performed. Even more troublesome are allegations that they performed unnecessary debridements on patients just to secure high reimbursements. Debridement reimbursements are usually around $325 per session.
The Healogics case is just one of many where hospitals have been accused of systematically upcoding and increasing patients’ risks and trauma just to generate higher revenue.
Manipulating oncology procedures
Though one would hope that a hospital wouldn’t abuse cancer treatments, this type of FCA violation has sadly become a recurring issue. On March 8th, 2016, the Department of Justice announced a $34.7 million settlement from 21st Century Oncology, a major radiation oncology provider, for allegations that the company had administered medically unnecessary radiation treatments.
21st Century Oncology physicians were accused of improperly administering and coding the Gamma function procedure. This procedure measures the amount of radiation remaining in a patient after treatment. The company allegedly allowed untrained individuals to administer the treatment, performed the treatments on patients who didn’t need it and billed for the treatment before reviewing the results or following the appropriate protocol. The allegations were brought forth by whistleblowers.
In March 2015, a similar case was settled against Adventist Health System Sunbelt Healthcare Corporation. That lawsuit, also enabled by a whistleblower’s report, alleged that Adventist allowed unqualified technicians to administer targeted radiation treatments.
Falsely diagnosing patients
False diagnoses are a jarringly prevalent form of FCA fraud that some hospitals and providers have used to defraud the government. This is an egregious offense regardless of the diagnosis itself, but some offenders take this type of fraud to truly astounding levels.
On March 4th, 2016, Dr. Isaac Kojo Anakwah Thompson, a Florida internist and medical clinic operator, pled guilty to defrauding Medicare Advantage by falsely diagnosing almost 400 patients with a rare chronic disease.
From 2006 to 2010, Anakwah defrauded millions of dollars from Humana’s Medicare Advantage program. He routinely diagnosed his patients with ankylosing spondylitis, an inflammatory spine disease that alters patients’ posture and affects their breathing. This disease does not have a specific diagnostic tests, which may be one of the reasons Anakwah used it as a vehicle for fraud. He was able to receive Medicare reimbursements without incurring costs related to the actual treatment of this disorder. Anakwah now faces up to 10 years in prison.
In 2015, a Michigan oncologist faced serious allegations of falsely diagnosing hundreds of patients with cancer so that he could bill insurance companies for chemotherapy treatments. He was also accused of giving unnecessary chemo to patients who did have cancer but whose prognosis made them unfit candidates for the treatment. He was even accused of suggesting chemotherapy rather than emergency care for a patient who had just experienced a head trauma, which allegedly resulted in the patient’s death.
Is it safe for hospital employees to report misconduct?
It may seem like these cases are outliers or that the offenders are the exception rather than the rule, but fraud is extremely common in many hospitals around the nation. It can be difficult to speak up when you witness fraud, whether it’s perpetrated by a colleague, a superior or by an affiliated provider like Healogics.
Most people’s instinct is to give their employer the benefit of the doubt, but when patients aren’t getting the treatment they should, it’s important to question the intentions of people and corporations who abuse federal healthcare systems.
Though reporting fraud in your workplace isn’t easy, it is protected by law. Furthermore, any employer that attempts to retaliate against you for blowing the whistle about healthcare fraud is breaking the law. Learn more about the rights of healthcare whistleblowers here.