Welcome to the The Whistleblower and the Healthcare Corporation blog. To those of you reading about Patricia Moleski for the first time, welcome to a real-life David and Goliath drama. If you are someone who has been following this story from its beginning on the Adventist Today blog, here is the story that Adventist Today became so uncomfortable featuring that the final chapters of Patricia’s story have to be told here.

Like many stories, the context in which this one takes place is almost as important as the story itself. Consequently, the story that appeared on the Adventist Today blog has been referenced with a link for easy access to readers’ comments.

Wednesday, September 19, 2012

AHS Update


UPDATE
Chapter 6, Patricia's final post, will follow shortly.

Florida Hospital whistle blower case widens to emergency departments

by Marni Jameson, Orlando Sentinel
Wed Oct 17 2012 6:30 PM

A whistleblower case alleging that Florida Hospital and six affiliates knowingly overbilled Medicare "tens of millions of dollars" in radiology services has widened to include the hospitals' emergency departments, according to an amended complaint filed this month.



The new complaint against Adventist Health System, which owns the hospitals, alleges that routine billing fraud occurred in the emergency departments from 2001 to 2008 and possibly longer, said Marlan Wilbanks, attorney for the whistle-blowers.



One of them, Amanda Dittman, worked in Florida Hospital's billing department during that time and claims in the suit that the hospitals routinely submitted false, duplicate or padded medical claims for emergency services, too.



The new allegation "fits like a glove with the original complaint," Wilbanks said. "It demonstrates the same lack of overall institution supervision."



The original complaint, filed in July 2010, claimed Florida Hospital used improper coding from 1995 to 2009 to overbill Medicare, Medicaid and Tricare, all federal government payers, for radiology services.

The suit also alleges that the hospital routinely overbilled for a drug — octreotide — used to enhance MRI scans by billing for larger doses than were actually administered. It also alleges that bills were issued for computer-aided-detection analyses that were never performed.



For instance, in 2006 the CAD system, which helps doctors interpret mammography scans, wasn't working, yet the hospital billed for the CAD scans anyway, the suit alleges. The hospital never refunded the money, according to the suit.



When asked for comment, Florida Hospital spokeswoman Samantha O'Lenick issued this statement: "Florida Hospital takes seriously our obligations under the law. If we discover mistakes, we take appropriate action to correct them.

"However, we believe the recent allegations relating to emergency room billings are asserted to achieve settlement pressure in the context of ongoing litigation. We believe the allegations are without merit, and we note that the relators had no involvement in emergency room billing. We will continue to defend the claims in court," the statement said.



Saw a pattern



The second whistle-blower in the case is Dr. Charlotte Elenberger, a radiologist affiliated with Florida Radiology Associates since 1995.

Dittman, a bill-coding and reimbursement-compliance officer, worked for Florida Radiology Associates from 1996 to 2001 before going to work for Florida Hospital.

Shortly after she began working at the hospital, she began to see a pattern, Dittman said.

"I saw the upcoding happening daily in heavy volumes across seven hospitals in the Orlando area," she told the Sentinel.

Dittman had computer access to systemwide billing records, she said.

"I could see all the accounts, the charges, dates of service, the payers, what was paid and when," she said.

She brought the errors to the attention of her superiors, she said.

"Soon I knew that they knew what was going on, and that they knew what they were doing was wrong, and they didn't want to correct it," Dittman said. "They were more interested in the bottom line than in doing the right thing."



In response to her concerns, the hospital system's financial-services directors conducted an internal investigation that confirmed double- and overbilling were occurring, the suit alleges, but did not correct the problem or refund the money.

"If there was a mistake, their culture was that they would not refund the money unless the payer specifically asked," Dittman said. "And then they would only refund the money on that one account, even though they knew how often it occurred."

Each hospital followed the same fraudulent guidelines, she said, adding that those who input the codes weren't aware they were upcoding.



At one point, Dittman said, she was told she was "being an obstacle." She has since relocated and now works for a hospital in California.

Motion to dismiss

Wednesday morning, the hospital system filed its second motion to dismiss the claim. Its first motion to dismiss was denied by U.S. District Judge John Antoon, who called the evidence "extensive and sufficient."



The seven Adventist hospitals listed in the complaint are Florida Hospital Orlando, Florida Hospital Altamonte, Florida Hospital Apopka, Florida Hospital East Orlando, Florida Hospital Celebration Health, Florida Hospital Kissimmee and Winter Park Memorial Hospital.

"We allege they knew exactly what was going on and they didn't change their practice," Wilbanks said.

"Basic errors were being made over and over in a very reckless fashion. It's not in doubt that these errors were being made. The question is how many times, and how much [money] did they keep that they shouldn't have kept?" he said.



Though the discovery process hasn't started, he said, the problem is systemic.

"Based on the paper trail we've seen, we have a basis for believing that this was a problem for a number of years," Wilbanks said.

If found guilty, Adventist would not only be responsible for repaying the excess money received, but also for paying damages and civil penalties of $5,500 to $11,000 per false claim, he said. The damages alone could easily be in the tens of millions of dollars, he added.

A trial is set for December 2013.

mjameson@tribune.com or 407-420-5158

 
Click here to view this article <http://mobile.orlandosentinel.com/k/4awyz> 


A whistleblower case alleging that Florida Hospital and six affiliates knowingly overbilled Medicare "tens of millions of dollars" in radiology services has widened to include the hospitals' emergency departments, according to an amended complaint filed this month.

The new complaint against Adventist Health System, which owns the hospitals, alleges that routine billing fraud occurred in the emergency departments from 2001 to 2008 and possibly longer, said Marlan Wilbanks, attorney for the whistle-blowers.

One of them, Amanda Dittman, worked in Florida Hospital's billing department during that time and claims in the suit that the hospitals routinely submitted false, duplicate or padded medical claims for emergency services, too.



The new allegation "fits like a glove with the original complaint," Wilbanks said. "It demonstrates the same lack of overall institution supervision."

The original complaint, filed in July 2010, claimed Florida Hospital used improper coding from 1995 to 2009 to overbill Medicare, Medicaid and Tricare, all federal government payers, for radiology services.

The suit also alleges that the hospital routinely overbilled for a drug — octreotide — used to enhance MRI scans by billing for larger doses than were actually administered. It also alleges that bills were issued for computer-aided-detection analyses that were never performed.

For instance, in 2006 the CAD system, which helps doctors interpret mammography scans, wasn't working, yet the hospital billed for the CAD scans anyway, the suit alleges. The hospital never refunded the money, according to the suit.



When asked for comment, Florida Hospital spokeswoman Samantha O'Lenick issued this statement: "Florida Hospital takes seriously our obligations under the law. If we discover mistakes, we take appropriate action to correct them.

"However, we believe the recent allegations relating to emergency room billings are asserted to achieve settlement pressure in the context of ongoing litigation. We believe the allegations are without merit, and we note that the relators had no involvement in emergency room billing. We will continue to defend the claims in court," the statement said.



Saw a pattern



The second whistle-blower in the case is Dr. Charlotte Elenberger, a radiologist affiliated with Florida Radiology Associates since 1995.

Dittman, a bill-coding and reimbursement-compliance officer, worked for Florida Radiology Associates from 1996 to 2001 before going to work for Florida Hospital.

Shortly after she began working at the hospital, she began to see a pattern, Dittman said.

"I saw the upcoding happening daily in heavy volumes across seven hospitals in the Orlando area," she told the Sentinel.

Dittman had computer access to systemwide billing records, she said.

"I could see all the accounts, the charges, dates of service, the payers, what was paid and when," she said.



She brought the errors to the attention of her superiors, she said.

"Soon I knew that they knew what was going on, and that they knew what they were doing was wrong, and they didn't want to correct it," Dittman said. "They were more interested in the bottom line than in doing the right thing."

In response to her concerns, the hospital system's financial-services directors conducted an internal investigation that confirmed double- and overbilling were occurring, the suit alleges, but did not correct the problem or refund the money.

"If there was a mistake, their culture was that they would not refund the money unless the payer specifically asked," Dittman said. "And then they would only refund the money on that one account, even though they knew how often it occurred."

Each hospital followed the same fraudulent guidelines, she said, adding that those who input the codes weren't aware they were upcoding.



At one point, Dittman said, she was told she was "being an obstacle." She has since relocated and now works for a hospital in California.

Motion to dismiss

Wednesday morning, the hospital system filed its second motion to dismiss the claim. Its first motion to dismiss was denied by U.S. District Judge John Antoon, who called the evidence "extensive and sufficient."



The seven Adventist hospitals listed in the complaint are Florida Hospital Orlando, Florida Hospital Altamonte, Florida Hospital Apopka, Florida Hospital East Orlando, Florida Hospital Celebration Health, Florida Hospital Kissimmee and Winter Park Memorial Hospital.

"We allege they knew exactly what was going on and they didn't change their practice," Wilbanks said.

"Basic errors were being made over and over in a very reckless fashion. It's not in doubt that these errors were being made. The question is how many times, and how much [money] did they keep that they shouldn't have kept?" he said.



Though the discovery process hasn't started, he said, the problem is systemic.

"Based on the paper trail we've seen, we have a basis for believing that this was a problem for a number of years," Wilbanks said.

If found guilty, Adventist would not only be responsible for repaying the excess money received, but also for paying damages and civil penalties of $5,500 to $11,000 per false claim, he said. The damages alone could easily be in the tens of millions of dollars, he added.

A trial is set for December 2013.

mjameson@tribune.com or 407-420-5158

 
View this article at <http://mobile.orlandosentinel.com/k/4awyz>

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