The federal government and the whistleblower community scored another big win last week when Amedisys, Inc. agreed to a $150 million settlement to resolve allegations of false home healthcare and hospice billings. This case is one of many False Claims settlements that raked back government healthcare funds. Last year, for example, nearly 88 percent of about $3 billion dollars recovered through whistleblower-filed false claims cases came from U.S. Department of Health and Human Services contractors.
These results remind me of something Attorney Kirk Nahra said in an exclusive interview with FierceHealthPayer: Anti-Fraud: "Research and anecdotal evidence show most whistleblowers brought problems to their companies' attention and only became whistleblowers when problems weren't fixed." That speaks volumes about the obstacles fraud fighters face.
First, there's the dysfunctionality of fraud-ridden organizations. Many claim to have open-door policies when actually they restrict discussion and dissent, even at the board level. They rationalize their behavior and avoid self-examination. Their executives may use fear to control employees. So there are no safe places within their walls for honest people to ask questions or report problems.
Secondly, Nahra's statement hints at the hard road whistleblowers travel. If they manage to report wrongdoing, to point out that the emperor has no clothes, they're often rebuffed. They may be stigmatized by the label of "not a team player," or they're fired, transferred or otherwise retaliated against. A troublemaker's reputation can precede them when they apply for new work. And instead of finding themselves on the cover of Time magazine as person of the year like Enron's Sherron Watkins, they're sometimes branded as rat-finks.
False claims cases can take years to resolve unless the government expedites them, and relators' lives can be turned upside down in the interim. Jeffrey Wigand, for example, the nationally-known whistleblower whose case was portrayed in the film "The Insider," said in an interview that Brown & Williamson knowingly manipulated its tobacco mix to increase the amount of nicotine in cigarette smoke. He later received anonymous death threats. One special investigations unit professional drove witnesses back and forth to court repeatedly because they feared retribution by providers whose medical licenses were on the line. Whistleblowers have lost their homes and uprooted their families.
In a complaint against Amedysis, whistleblowers alleged that employees used a proprietary laptop program to gather beneficiary data that resulted in Medicare overpayments. A corporate system also reportedly augmented billings. Whistleblowers called the laptop program and billing system combination the "secret sauce."
There's always a new sauce in the determined criminal's pantry. Unlike honest providers who admit their errors, learn from them and make amends, fraudsters can be recalcitrant. Even sanctioning may not stop them from defrauding again. Medicare, for example, paid more than $6 million in 2012 to doctors who were thrown out of Medicaid, indicted or charged with fraud, or had settled false claims allegations.
But this week at least one whistleblower breathes easier. Former Amedisys employee April Brown will collect more than $15 million for being the first to expose the company's alleged fraud. She plans to lead a quiet farm life with her children and keep nursing the poor and elderly in her community.
"She just did what she knew was right even though it caused her great hardship in the process," Brown's lawyer said. "She's a tough, honest, smart woman, and this country needs more people like her." - Jane (@HealthPayer)