Lelan Daines was shocked when a flier for a symposium titled “Bridging the Gap Between Law Enforcement and Health Care Providers” crossed her desk at Salt Lake Regional Medical Center.
Nothing in her nursing and hospital administration training prepared her for dealing with the chasm between two of society’s most essential services. But there she and her colleagues were Thursday in a room full of FBI agents and federal prosecutors talking about health-care fraud.”I shouldn’t have to have a law degree in order to provide care to patients,” she said. “It would never occur to us to do fraud. That’s how most nurses and doctors are.”
Nevertheless, health-care providers are ripping off Medicaid and Medicare to the tune of an estimated $30 billion a year nationally. And federal and state governments are going after them with a vengeance. Utah is no exception.
Hospitals, medical supply firms and physicians believe no one is safe from the stinging prosecutorial needle no matter how hard they try to comply with a complex set of ever-changing regulations. Some are abandoning the medical profession while others are deciding not to go into it at all.
“I feel like I’m in a kennel,” said Bountiful urologist Dr. Perry Walters. “When do I get castrated?”
The U.S. Attorney’s Office for Utah organized Thursday’s conference to begin mending what has turned into an extremely adversarial relationship between the health-care industry and police agencies. In addition to speakers from both sides, assistant U.S. attorney Mark Hirata moderated a panel discussion called “Dealing with Law Enforcement at Your Doorstep.” There was little give and take in the sometimes vitriolic discussion.
“We obviously haven’t bridged the gap here,” Hirata said. “I’d like to think this is a first step in that direction.”
If Utah follows the nation, about 10 percent or $70 million of its annual federal medical assistance funds will be lost to fraud, waste and abuse, said Denis Kroll, director of the state attorney general’s medical fraud unit. The figure, he said, is not a quota, as one symposium participant suggested.
“There’s no target amount to collect. All we’re trying to do is detect and prevent fraud,” Kroll said.
Robert Pocica, an FBI supervisory special agent for the Health Care Fraud Unit in Washington, D.C., said there are hundreds of different schemes to bilk Medicaid and Medicare, with billing for services not rendered topping the list. Others include double billing, billing separately for a group of lab tests and billing for a more highly reimbursed service than was provided.
The federal government chases only the most egregious cases, he said. The FBI, which receives $548 million a year to investigate medical fraud, has neither the resources nor the staff to target specific providers, Pocica said, but acts solely on complaints.
U.S. Attorney Paul Warner said his office in Salt Lake City isn’t interested in prosecuting honest mistakes or negligence or stupidity. He said he pursues cases that involve criminal intent.
“We’re talking about a very small percentage of bad apples, people who are trying to cheat the system. That’s who we’re going after,” said Hirata, Warner’s chief health-care fraud prosecutor.
Warner did make it clear that fraud investigations aren’t going away.
“There always seems to be a crime du jour,” he said. “Health-care fraud has been the crime du jour the past several years.”
Dr. George Cannon, past president of the Utah Medical Association, sees the government crackdown on health-care fraud as harassment. Encouraging people to look for wrongdoing drives a deep wedge in the patient-doctor relationship, he said. The approach, he said, is heavy-handed, and raids come off like a drug bust.
Doctors aren’t accustomed to federal investigators showing up in their full waiting rooms demanding patient records. Nor are hospitals used to armed FBI agents issuing no-knock search warrants in their radiology departments.
“What seems to a law enforcement officer like a routine duty becomes to us a life-altering experience,” Cannon said.
Health-care practitioners have three options, said David Gessel, vice president of government relations and legal affairs for the Utah Hospitals and Health Systems Association. Providers can attempt to comply with the rules, get out of the business or cast a blind eye and hope. He sees the first option as the only “rational” way to go.
Gessel, however, cautioned police agencies not to paint every medical professional with the same brush. The federal government, he said, has taken the tack that no one in the industry is exempt.
“That’s the message that’s being sent. That’s why there’s conflict. Most of these people’s experience with law enforcement is a ticket on the road,” he said. “We’re the political soccer ball of the ’90s or the pinata of the ’90s.”