A whistleblower will receive $2.16 million for helping Medicare recover
$8 million taken from it by fraud. Darlene Tucker, a former administrator
at Southern Crescent Hospital, filed a False Claims Act lawsuit against
Dubuis Health System, and her employer, Southern Crescent Hospital for
Specialty Care, Inc. She alleged that, due to the long-term, acute care
facility’s Medicare fraud, patients were being kept at the hospital
even after they no longer needed the medical care – all so that
Dubuis and Southern Crescent could bilk Medicare of a few more bucks per patient.
Joshua Schwitzerlett, a reporter with the Ring of Fire, described the case
in an article,
$8 Milllion Hospital False Claims Settlement, Whistleblower Gets $2.16 Million. Dubuis and Southern Crescent treated patients who were extremely ill,
and needed acute care. These patients were expected to need care for a
lengthy period of time. Tucker’s suit alleged, however, that from
2003 to 2009, Dubuis and Southern Crescent kept patients in the hospital
well past the time the patients needed acute care. According to the suit,
the extended stays were not medically necessary. In fact, the only reason
that Dubuis and Southern Crescent were keeping the patients in the hospital
was so that the facility could keep billing Medicare for the patients’ care.
Obviously a patient does not enter long-term, acute care unless the patient
is very ill. By definition a patient is admitted for acute care because
he or she has a complex illness. Second, the patients’ doctors have
acknowledged that the patient is going to need that high level of care
for more than 25 days.
On the other hand, many or most of these patients are going to improve
eventually. They are not being given a life sentence in the hospital.
When they get better, like every other hospital patient in the world,
they want to get out of the hospital and go home.
The False Claims Act is meant to address exactly this sort of fraud. The
statute is aimed at people who are swindling the Government in some way.
The FCA covers fraud against Medicare, Medicaid, the military, or any
other Government agency. But here the case was especially important because
what the Defendants were doing did more than rob the taxpayer coffers;
it also affected the lives of innocent people who were confined in a hospital
when they should have been allowed to go home to their families.
The DOJ did not release much information about how the fraud worked. It
is hard to imagine a doctor listening to a patient beg to go home, and
then looking the patient straight in the eye and telling him that he needs
to stay in the hospital – even though the doctor does not actually
believe the patient needs to stay in the hospital. Even if the hospital
was pressuring the doctor, it is just hard to believe that a doctor would
keep a patient from going home to his family simply because the doctor
was hoping to squeeze a few more dollars out of the patient’s Medicare
coverage. Perhaps the fault lay entirely with the long-term care facility.
The hospital may have been overriding the doctors’ orders to send
patients home – also a very frightening possibility, since it raises
the specter of a hospital interfering with the medical care its patients
are receiving.
Regardless of just how the fraud was being executed, it certainly is the
type of behavior that needs to stop. Congratulations and thank you to
Ms. Tucker and to colleague James Kauffman, who was Ms. Tucker’s
whistleblower lawyer.