Jeff HeltonIn the past month, there have been several news headlines concerning prosecution of healthcare providers for alleged acts of fraud. Considering the fact that the healthcare system continues to be in the news because of the healthcare reform debate, having our industry highlighted for fraudulent acts seems to put an even darker cloud over public perception of the industry. The Gallup organization says that a large percentage of the American public does not trust the healthcare system at this time. Although much of that circles around the health reform legislation, we are nonetheless and unwitting participant in that negative perception.

Looking over details of these recent prosecutions, much of the attention has focused on the provision of medically unnecessary services and problems with Medicare secondary payer (MSP) billings. MSP billings have been a historic problem for many of us, despite our best intentions. However, recent prosecutions in this area seem to be initiated by qui tam relators, otherwise known as whistleblowers.  Unfortunately, some of these organizations were not aware of the problem until approached by investigators from the Office of Inspector General (OIG).  What are you doing to be sure you are not the victim of such a surprise?

Historically, whistleblowers seem to have been the sources for medical necessity prosecutions.  That continues to be borne out in recent prosecution headlines. Although a couple of the recent headlines related to organized crime schemes, they were still initiated by a whistleblower. Do we know that there are not schemes being perpetrated without our knowledge?

What can we do as leaders to show our best efforts to do the right thing and preserve the public image of integrity we find most valuable? Here are a few suggestions.

Talk to people. Let’s show that we have a genuine interest in doing the right thing and evidence it by meeting with those people who can give us the best information: the staff doing the “hands on” work.  Let’s ask questions about what they do and how they do it, and maybe even have a few random walk-throughs of accounts or transactions.  Let’s ask questions about things that we don’t understand or that don’t look right. Showing that direct interest can certainly instill confidence in our staff that we care about the integrity of the organization. Establishing an open relationship with the person who could be a whistleblower might be the best defense we could have against an OIG surprise. Perhaps they might even try to tell us something before they tell the OIG.

Look in the mirror. At least one prosecution that hit the headlines this past month involved compensation to referring providers. When was the last time we looked at our disbursements to referring providers with an eye toward making sure they were appropriate under current law? Things like gift cards, coupons, and direct payments to vendors on behalf of referral sources were the centerpieces of one particular case.

Set the tone. Leaders that consistently demonstrate a commitment to integrity, following the rules, and showing no tolerance for straying into the gray areas set the expectation for those we work with.  That “tone at the top” has been shown to be a significant deterrent to fraudulent activity within an organization.

Now that the federal government has at least partially shut down due to the healthcare reform debate (or is it “stalemate”?), we have an even greater risk as financial leaders in the healthcare industry. The Centers for Medicare & Medicaid Services (CMS) issued a bulletin indicating that they would not be funding any of its current fraud oversight and monitoring programs during the shutdown.  Therefore, we have a potential risk for the industry’s image to be further blemished by the lack of oversight to catch and prosecute the miscreants who hurt the reputations of the vast majority of us who try to do the right thing.  

As with so many things in life, those of us who try to do the right thing also carry the burden for those who do not when headlines point toward a hospital or a provider as a defendant in a fraud case. We certainly cannot eliminate these problems from the healthcare landscape. As long as there is so much money in our industry, the criminals will come. However, if we as leaders set the tone that such fraud and abuse is not tolerated, and if we take proactive action to report things we see to the authorities, we contribute our part to preserving the image and reputation of our industry. 


Jeffrey Helton, PhD, FHFMA, CMA, CFE, is assistant professor, Metropolitan State University of Denver, and a member of HFMA’s Colorado Chapter.

Publication Date: Wednesday, October 02, 2013