Whistleblowers play a critical role in the fight against rising healthcare costs. The biggest area of fraud costing the government billions of dollars of fraud annually is the Medicare program. Because Medicare is subsidized with tax dollars, healthcare providers that bill for unnecessary services hurt everyone. One area where fraud is particularly rampant is in nursing homes and assisted living facilities.
Pro Publica and Frontline recently did an expose on the poor care received by some assisted living facility patients. After seeing their report, we realized that there are many opportunities for whistleblowers. Although their investigation focused on quality of care issues, healthcare fraud and patient abuse often go hand in hand.
A case in point is their story about a healthcare company called Emeritus. Most states require a medical evaluation before a patient can be admitted to an assisted living facility. The law is to insure that only people who meet the facility’s criteria are admitted. Some very sick patients are simply too ill to benefit from assisted living and may require a skilled nursing home or even a hospital.
According to the story as reported by Pro Publica, in 2008 Emeritus commenced a program called “No Barriers to Sales.” The concept was simple, place as many people as possible into their facilities. They say that a company vice president sent an email to employees directing that “SALES and your commitment to sales” was to become employees’ top priority. In the words of the company’s quality control manager, the goal was to “put heads on beds”.
One former facility manager claimed the company’s new priority was to make as much money as possible. Some claim that the policy resulted in people too sick or unstable being placed in assisted living. Unfortunately, these facilities generally lack the trained medical personnel and high level of supervision of nursing homes.
According to the story, one patient was admitted without a medical examination and subsequently died. Thereafter, one of the whistleblowers who complained about problems in the company was apparently terminated for “poor performance” (a common tactic by businesses with something to hide).
It’s unclear what happened with the fired whistleblower (the company apparently settled on confidential terms) and whether any violations by Emeritus were isolated or part of widespread fraud. The company denied the allegations.
The point of the story is that whistleblowers play a pivotal role in stamping out fraud and misuse of Medicare and Medicaid monies. By doing so, they may also save lives and improve care.
Fear of retaliation keeps many whistleblowers from coming forward. (Many of the people we speak to come forward after they are fired.) Federal and most states have enacted whistleblower protection laws that force companies to rehire or compensate wrongfully terminated whistleblowers.
An even more potent tool is the federal False Claims Act. Under that law, whistleblowers are entitled to an award of up to 30% of whatever the government collects from the people committing the fraud. With much of assisted living and nursing home care paid by Medicare, a company that falsely bills or unnecessarily fills bed with clients who don’t meet proper medical criteria may wind up repaying millions to the government.
To earn an award, whistleblowers must have original source information and must be able to show a loss to government funds or a government-funded program. The process is started when the whistleblower files a complaint under seal in the federal court.
If you wish to become a whistleblower and have inside, non-public information about fraud against the government or involving federally funded programs, give us a call. We represent whistleblowers and help them stop fraud and collect the largest award possible.
For more information, contact attorney Brian Mahany at or by telephone at (414) 704-6731 (direct). All inquiries are protected by the attorney – client privilege and kept in strict confidence.
Mahany & Ertl – America’s Fraud Lawyers. Offices in Milwaukee, Wisconsin; Detroit, Michigan; Minneapolis, Minnesota; Portland, Maine and San Francisco, California. Services available in many jurisdictions.
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Posted by Brian Mahany, Esq.