Since 2009, federal prosecutors have recovered over $16 billion in Medicare fraud cases. Although the recovery certainly sounds impressive, the FBI estimates we lose tens of billions of dollars annually because of healthcare fraud. Because of whistleblower cases such as that filed by Dr. Jean Moore, the government is starting to make progress in its war against fraud.
Last year the Justice Department paid out over $635 million in whistleblower awards, a record year. (Our clients received over $100 million in award monies.)
This post looks at the actions of Dr. Moore, a pediatrician who practices at Mercy Clinic Springfield Communities (St. John’s Clinic) in Springfield, Missouri.
Beginning in 2013, Dr. Moore received a bonus payment called “specialty funding.” She claimed that hospital administrators admitted there was a potential problem with these payments yet merely tinkered with the formula. According to her, the payments were nothing more than a thinly disguised payment for patient referrals.
Federal law prohibits hospitals from paying or awarding physicians who refer patients. The goal of the healthcare system is basing care on the best needs of the patient, not how much bonus one might receive. Doctors don’t want their pay tied to how many patients they admit or refer.
Most hospitals know that directly tying compensation to referrals is illegal. Some hospitals, however, come up with bonus schemes or other incentive packages to hide their actions. According to Dr. Moore’s complaint, the hospital admitted it had a problem in 2012 but instead of fixing the problem, simply concocted a different name for the payments and a different formula.
Mercy Clinic agreed to pay $5.5 million to the federal government to settle the charges. The defendants were not required to admit to any wrongdoing. For his efforts, Dr. Moore received 15% of the recovery ($825,000).
In announcing the settlement, Kansas City, Missouri’s United States Attorney Tammy Dickinson said, “This settlement protects patients and the public by enforcing the federal protections against illegal profit incentives for physicians. A bonus structure that rewards physicians based on the value of their referrals is detrimental to both the quality and the cost of health care. Patients deserve assurances that they are receiving appropriate medical care, unbiased by hidden incentives. And taxpayers deserve assurances that the cost of public health care programs is not inflated by unnecessary procedures and services.”
Even not-for-profit hospitals struggle to make ends meet. Filling patient beds with patients who may not need in-patient care is not the solution, however. That simply transfers the hospital’s economic woes to patients and taxpayers.
If you know of Medicare fraud including hospital kickback schemes or payments for patient referrals (“patient recruiters”), please give us a call. In order to earn a whistleblower award, one must have inside information about the fraud. Awards are earned by filing a sealed complaint in federal court. The government then is given two months or more to investigate.
Congress and most states have passed tough whistleblower anti-retaliation laws. In most cases, the whistleblower’s name and identity is protected during the government’s investigation. We will gladly explain how the process works, what you can expect and whether you may have a case.
MahanyLaw – America’s Whistleblower Lawyers