By Mike Tobias
The FBI says health care fraud costs the United States tens of billions of dollars a year,Â and Nebraska is not immune from this crime.
Randy Reeder was living Doniphan, a small town between Grand Island and Hastings.[audio:https://kvnonews.com/wp-content/uploads/2015/06/HealthCareFraud_KVNO.mp3]
He was confined to a wheelchair and required a lot of help with everyday needs like getting out of bed, washing and getting dressed. Medicaid paid for home health care workers to assist him. All legal, except for the scheme Reeder developed with three workers, all independent contractors. Over several years, Susan Francis, Danielle Clark and Christina Baker billed Medicaid for more hours than they worked. Reeder aided and advised the workers in falsifying their time sheets.
Mark Collins helped prosecute this case. Heâ€™s a Nebraska assistant attorney general and head of Nebraskaâ€™s Medicaid Fraud and Patient Abuse Unit.
â€œ(Itâ€™s) not as bad as in other states, but surprisingly bad enough,â€ Collins said. â€œIn the 10 years that Iâ€™ve been here, weâ€™ve recovered over $70 million in fraud for the state of Nebraska.â€
Collins said the $70 million total is somewhat skewed by big cases involving multiple states and pharmaceutical companies. In a typical year his office will recover closer to $1 million from fraud cases. There are plenty of investigations similar to what happened in Doniphan. Collins said billings for services not rendered, like our example, is the main type of case. Another is called upcoding.
â€œEverything is based on a code that the provider has to submit,â€ Collins said. â€œEspecially in the case of professionals such as therapists, doctors, chiropractors, anybody of that nature. They submit something with a code that says, for example, how long the office call took. Maybe itâ€™s a short call. Maybe itâ€™s a medium-length call. Maybe itâ€™s a long one. If they have a short call, then they bill it as a medium call, thatâ€™s called an upcode.â€
â€œWhat we are seeing here is a lot of home health care fraud thatâ€™s starting up,â€ said Carrie Sawicki, who investigates health care fraud as a special agent in the FBIâ€™s Omaha Division office. â€œThe home health agencies, be it nursing services or LPN services and even housekeeping and personal aid services that Medicaid and some federal grant money pays for. Weâ€™re seeing kind of an uptake in some fraud there.â€
She said theyâ€™re also seeing an increase in fraud related to overbilling for hospice services. Sawicki said of any these fraud cases that involve a caregiver coming into a home present challenges for investigators.
â€œItâ€™s an intimate relationship. Itâ€™s a relationship that a lot of the beneficiaries really rely on,â€ Sawicki said. â€œWhether theyâ€™re getting all of the services that are being billed for or not, they want someone to come to the house. A lot of times, itâ€™s elderly people or disabled people. They donâ€™t have anybody else to help them and so theyâ€™re just happy that someoneâ€™s coming that they can talk to a couple of times a week. They might not even know what has been, for lack of a better word, prescribed for them in terms of services.â€
â€œThese people submit their own bills for the services that they purport to render, so they donâ€™t have that check and balance thatâ€™s in the middle, that we would see with most licensed professions,â€ Collins added.
â€œA â€˜biggyâ€™ thatâ€™s going around the country right now is lab tests,â€ said Susan Rainey-Biler, special investigations supervisor for Blue Cross andÂ Blue Shield of Nebraska, the stateâ€™s largest health insurance company. â€œThe doctor will order one test and send it out, and the lab will perform 25 tests and bill for it. The member really doesnâ€™t necessarily know, but then they get the bill for $6,000 for testing and they think something is really out of whack and give us a call. The other big thing is always that a member might share their ID card, give it to their friend to use because their friend no longer has a job and just broke their arm. Thatâ€™s also a crime and we would look into that.â€
Many investigations are launched because the numbers donâ€™t add up. Time sheets submitted for payment may show a care provider in two different places at the same time, for example. Thereâ€™s a unit at Health and Human Services that looks for irregularities in Nebraska Medicaid claims. Possible cases are forwarded to the attorney generalâ€™s office, which opened 121 fraud investigations in the year that ended in March.
â€œThe methods that we have to investigate these crimes are pretty sophisticated as far as the way claims that they submit are analyzed,â€ Collins said, â€œand thatâ€™s where we find them. Those turn up as blips on the radar, if you will. Those are the ones who warrant a closer look and we do look. Not only do we look, but the folks at the Department of Health and Human Services who are dedicated to this very job look at this kind of stuff every single day.â€
Sawicki said there are examples in Nebraska where a patient is harmed by a provider performing unnecessary or unsafe procedures. But most of the time the victim in fraud cases is the entity providing the insurance, a private company or predominantly government programs like Medicare, Medicaid and Tri-Care (for members of the military).
But Collins said everyone is hurt by health care fraud.
â€œThatâ€™s what makes these kind of cases so important is because thereâ€™s only so much money that governments can pay out for these services and when youâ€™ve got someone out there who is defrauding the government, by not providing those services to someone, what happens then is not only is that person not getting any service, but the money thatâ€™s being paid is money that could have been used to care for another person as well,â€ Collins said.
â€œThe bottom line victim is the member because with the costs of fraud, itâ€™s going to make your insurance premiums go up,â€ Rainey-Biler said, â€œand itâ€™s less time that can be spent with your doctor because somebody else is using them for whatever reason. There might be more paperwork because weâ€™re now questioning various things, so you might have to do more paperwork.â€
Thatâ€™s why there are a lot of resources pursuing health care fraud cases in Nebraska. In the Doniphan case, the investigation led to felony charges against three of the people involved and a misdemeanor charge against the other; all four received probation. The caregivers who got paid more than they actually worked were ordered to pay more than $20,000 in restitution.
COURT DOCUMENTS FROMÂ THE DONIPHAN CASE
Details on howÂ this fraud case unfolded can be found in these Hall County Court transcripts for the four people sentenced:
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