Are You Working With A Whistle-Blower?

Funky Fraud Saturday Word Picture

Many doctors and healthcare providers think they will never be accused of healthcare fraud.  “It can never happen to me,” is the attitude many doctors have.  But what if your competitor decides to be a whistle-blower against you?  What if you put that competitor out of business?  In many healthcare fraud cases, the competitor becomes the whistle-blower.  It’s someone you worked closely with and shared much of your information, records, software, data, etc.

In the case we detail below, a pharmacy which went out of business becomes a whistle-blower and is rewarded with a payment of $5.97 million dollars for bringing whistle-blower actions against the other pharmacies that it competed with.

“[Owner of Ven-A-Care, T. Mark] Jones, now 57, turned his misfortune into a mission ignited by the company that nearly destroyed him.  National Medical Care Inc., then a unit of W.R. Grace & Co. (GRA), planned to prescribe medications for patients based on how much profit they would generate, Jones says.

He and his two partners decided to investigate exactly how NMC was making money. They found it was overbilling Medicare, cheating U.S. taxpayers. This practice, they later discovered, was widespread.  Big Pharma was routinely reporting inflated drug prices, leading Medicare and Medicaid to overpay doctors and pharmacies by billions of dollars. Jones and his partners dedicated their lives to exposing that hard-to-detect scheme.

Ven-A-Care, operating from a quiet street in Key West, has filed whistle-blower lawsuits against dozens of pharmaceutical companies since 1995 — many later joined by the U.S. and states — that have recovered more than $3 billion for the U.S. government”

Bloomberg News, August 13, 2013

How do you protect against this?  Do you have a compliance plan?  Do you have a routine internal and external audit to make sure you comply with current laws and regulations?  When is the last time your staff was trained?  Do employees know who to talk to if they think someone is violating the law?  Do you have a policy that requires employees to raise any issues with the compliance officer?  Do you routinely do exit interviews with your employees to find out why they are leaving?

You need to be able to easily answer these questions.  “An ounce of prevention is worth a pound of cure.”  Healthcare providers pay hundreds of thousands of dollars defending whistle-blower actions and insurance audits.  For the many offices who go through these difficult legal proceedings, they often wished they had taken compliance more seriously.  If you can identify a problem before a whistle-blower does, you will save yourself a lot of time and money.

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