Currently Viewing:

When Healthcare Fraud Gets Personal

Ms Jacobs is the chief operating officer for PCG Software and has more than 25 years' experience in the healthcare industry, encompassing both administrative and clinical arenas. Prior to joining PCG, Ms Jacobs was the administrative director, medical management for VertiHealth Administrators. Previously, she was an independent consultant in ambulatory care and practice management, where her clients have included hospitals, physician groups, and the University of California, Los Angeles.
You may remember last year Tenet Healthcare settling federal fraud charges related to Medicaid maternity claims at 2 hospitals. The agreement included a $513 settlement, an admission of guilt from the 2, and a non-prosecution agreement as long as the provider cooperated with ongoing investigations.

But you may not have seen the latest—the January indictment of a former Tenet senior vice president who was implicated in the scheme. John Holland could face up to 50 years in prison if convicted of federal charges of using bribery and kickbacks to steer Medicaid business to Tenet hospitals. Holland pleaded not guilty.

In a statement, Holland’s attorney denied the charges, saying the contracts in question were more than 10 years old, had been reviewed by multiple levels of the company, and that Holland didn’t benefit personally from the fraud. The feds filed forfeiture notices against 2 homes the former Tenet executive owns.

Going after individuals following corporate fraud investigations has been anticipated since a 2015 Department of Justice directive to focus more on individuals. The indictment of Holland follows a similar action against an Oklahoma official accused of taking kickbacks in exchange for giving out lucrative ambulance services contracts, according to an article in Bloomberg BNA's Health Care Daily Report.

Watch Your Claims and Your Payers Closely

What does this mean for you and your company? It means that you could be personally liable for the actions of others in your company, especially if you had the means to ferret out the fraud or the kickbacks yourself.

The data you need is there, within your claims. Analytics programs can show you aberrant patterns of claims, for example, doctors who are seeing high volumes of certain types of patients or writing large numbers of prescriptions for opioids or other controlled substances.

If your company contracts out services or issues procurement contracts, does one person have the final authority to say yes or no? Giving that type of power to one person can lead to abuse of that authority. You want dual authority, at least, or a committee to sign off on any contracts to keep everything aboveboard.

Regardless of how intricate the scheme, it seems that the bad guys get caught sooner or later. Don’t let yourself get caught up in someone else’s mess, especially when you had the means at hand to monitor the situation. 

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up