Healthcare fraud runs the gamut of unethical behaviors, but compromising the treatment of cancer patients has to be one of the most serious offenses. As you can imagine, it is extremely important that only fully qualified medical professionals administer radiation treatments, which use targeted, regulated doses of intense radiation to kill cancer cells. For patients under the umbrella of Medicare or TRICARE, the Department of Defense healthcare program, government regulations therefore require that radiation therapy only be administered under the direct supervision of radiation oncologists or similarly qualified medical professionals.
In 2013, a Florida radiation oncologist filed a qui tam lawsuit against Adventist Health System Sunbelt Healthcare Corporation alleging that the company’s hospitals violated those legal requirements. The lawsuit accused multiple Adventist hospitals in Florida of administering radiation treatment from 2010 through 2013 without meeting the supervision requirements.
Justice for Florida hospital patients
On March 19th, 2015, Adventist settled the allegations with a payment of $5,412,502 to the government, concluding the two-year investigation. Attorneys John Yanchunis and James Young of the Morgan & Morgan Complex Litigation Group represented the qui tam client after being referred by attorney George Indest of The Health Law Firm. In addition to the government settlement, the whistleblower was awarded $1,082,500 for his essential role in this case.
Young applauded his client’s commitment to taking action against Medicare Fraud: ‘“Our client is a remarkably courageous physician. Throughout this case his focus has been on protecting patients. As a firm, we are proud to have represented him.”’
Healthcare fraud is top-of-mind for the federal government, but it is very difficult to prosecute without the help of whistleblowers. In most cases, the only other way for the government to discover violations of the False Claims Act is through reports submitted directly from hospitals and healthcare providers that participate in Medicare, Medicaid or TRICARE programs. For obvious reasons, organizations that knowingly commit fraud are unlikely to be transparent about it in their official reports. Whistleblowers in the healthcare system provide necessary insight into fraud because they have access that the government does not.
Healthcare fraud is a recurring problem
Across the healthcare sector, fraud is rampant. Recent estimates put fraud’s financial impact on Medicare and Medicaid alone at nearly 10% of the program’s overall spending, which amounts to almost $100 billion in additional costs. This is a frustrating issue for the government, in large part because of the challenges in spotting fraud. It directly impacts taxpayers, whose hard-earned money sustains these federal programs. Fraud especially has a negative impact on the millions of Americans who rely on federal healthcare programs, because it can detrimentally diminish their quality of care and endanger their lives.
This type of False Claims Act violation may not initially seem like a significant issue to healthcare professionals and can easily happen within hospital settings. The success of this case demonstrates clearly, however, why government guidelines should be followed. For cancer patients, radiation therapy can be a terrifying prospect. They deserve the reassurance that the individuals treating them are fully capable of administering the appropriate doses and correctly targeting cancer cells. A lax attitude about supervisory guidelines in radiation oncology is thus negligent at best.
The Adventist settlement also highlights the enormous impact that one individual can have in righting a systemic wrong. The whistleblower’s actions demonstrated a great deal of integrity and a commitment to upholding both necessary government standards and the spirit of the Hippocratic Oath. That courage sets an important precedent and may even enable further accountability within the same organization.
Another settlement for Adventist
Several months after the radiation oncology case, Adventist faced yet another legal battle. The company was accused of a number of illegal financial arrangements, including unlawful compensation of referring physicians and financial incentives for hitting certain testing quotas. The company settled the allegations through a payment of $115 million to the U.S. government. This qui tam case was brought to light by three whistleblowers, who had been Adventist hospital or corporate employees.
With the help of whistleblowers, the government’s health care fraud initiatives have enabled the Justice Department to recover more than $16 billion in defrauded funds since 2009.