Coders and billing professionals are the backbone of the healthcare industry. Without proper coding, doctors, therapists and hospitals don’t get paid. Because of their unique position within the healthcare industry, a coder is often in the best place to spot fraud.
As healthcare costs spiral out of control, the Centers for Medicare and Medicaid Services is really cracking down on Medicare fraud. Not a day goes by without the Justice Department announcing another multimillion dollar settlement or prison sentence handed down to a physician or other healthcare professional. In this post we will look at the recent settlement between the U.S. Department of Justice and Vibra Healthcare LLC… a settlement in which health information coder Sylvia Daniel is to receive an award of at least $4.9 million!
Vibra Healthcare’s Medicare Fraud Prosecution
According to Sylvia Daniel’s original lawsuit, Vibra was unnecessarily hospitalizing patients whose conditions didn’t require that level of care and keeping existing patients in hospitals longer than necessary
Because the court clerk has yet to release the seal on the case, we cannot yet share the full facts in the complaint. We can share, however, that Vibra is a hospital chain headquartered in Pennsylvania. The company operate hospitals and rehabilitation facilities in 18 states.
According to prosecutors, in five of Vibra’s long term care hospitals and in one of its rehabilitation facilities, the company admitted many patients who “did not demonstrate signs or symptoms that would qualify them for admission.” The government also claimed that Vibra extended the stays of some of its patients without regard to medical necessity, qualification or quality of care. At times, Vibra even ignored its own staff who were urging that certain patients were ready for release.
The case settled this week before trial with Vibra agreeing to pay $32.7 million. The company did not have to admit liability as part of the settlement.
Prosecution Began by a Coder
Like many successful Medicare prosecutions, this case began with a whistleblower. The true hero of this story is Sylvia Daniel, a former coder who worked at Vibra Hospital of Southeast Michigan.
Coders are often some of the first people to see a pattern of fraud. When their client or employer won’t fix the problem, these folks often decide to become a whistleblower and come to us. For example, one coder quickly figured out that a physician was allegedly seeing so many patients that he would have to work 27 hours per day. Another coder uncovered a kickback scheme where patients with Medicare or good insurance were being passed around the same group of doctors. Yet another knew a particular doctor was on an out-of-state vacation yet was still billing for “seeing” patients in the office.
Medicare Fraud and Whistleblower Awards
Daniel’s case was filed under the federal False Claims Act. That law allows ordinary people with inside information about healthcare fraud to file a lawsuit in the name of the United States. Approximately 29 states have similar laws that cover state funded Medicaid spending.
Under these laws, if the government uses your information, you could receive an award of between $15% and 30%. Here, that means Ms. Daniel will receive a check for at least $4,905,000.00. Not a bad paycheck for standing up to greed and fraud. In this case, Sylvia Daniel may have saved lives too!
While some believe that Medicaid fraud is a victimless crime, it isn’t. In addition to the losses sustained by taxpayers, patients in this case may have been unnecessarily exposed to infectious disease risk. It is not uncommon for people to grow very ill as the result of a hospital stay. By admitting otherwise healthy people, Vibra Healthcare jeopardized patient safety.
In our line of work, we call that type behavior “profits before patients.”
In announcing the settlement, a senior Justice Department official said, “Medicare beneficiaries are entitled to receive care that is determined by their clinical needs and not the financial interests of healthcare providers. All providers of taxpayer-funded federal healthcare services, whether contractors or direct billers, will be held accountable when their actions cause false claims for medically unnecessary services to be submitted.” We agree.
Whistleblowers are the new American heroes. You don’t have to enlist in the Army and go to Afghanistan or become a firefighter to become a hero (although they certainly are heroes). The simple act of standing up against greed and bad healthcare makes one a hero. And with healthcare fraud costing taxpayers’ tens of billions of dollars each year, we need more heroes.
Coders are uniquely positioned to see fraud. Our mission is to empower the coder community (other insiders too), protect them from retaliation and obtain for them the maximum whistleblower award possible.
Want to learn more? For more information and a confidential, no obligation consultation, contact attorney Brian Mahany at or by telephone at (direct). Still not convinced? Our third year law student / law clerk “Joe” is a professional coder, educator and national lecturer on coding. We understand your language.
MahanyLaw – America’s Whistleblower Lawyers