False claims

Imagine a criminal enterprise so vast that it will give you a cut of any loot you can recover from crooks who double cross it, and you have the drift of the False Claims Act.  The modus operandi of the Federal government is simple: Pay us whatever we tell you in taxes or go to jail.  We will then spend this money however we please, on things primarily designed to get us reelected.

One of the favorite ways for federal officials to get reelected is buying votes through entitlement programs.  These multibillion-dollar programs are the very definition of complexity and, to no one’s surprise, multimillion-dollar frauds are as common as dirt.  The Feds don’t even attempt to enforce against many (most?) of the frauds, but rather offer an avenue for private lawyers to do the government’s work for it.

Medicare is commonly defrauded, probably to the tune of $80 billion annually.  The number is a bit misleading, however, because the Medicare billing rules are impenetrably convoluted.  It is easy for the Feds to call an honest billing dispute a fraud and then smash some doctor or hospital to show the poor taxpayer that someone is looking out for him.   A typical hospital “rip-off” works like the recent one St. Joseph’s Hospital of Atlanta settled for $26 million: St. Joseph’s charged inpatient fees for patients who were under long-term observation in the emergency room.  I don’t know that St. Joseph’s did anything dishonest and I do know that St. Joseph’s rendered some service for these fees; St. Joseph’s was not accused of submitting fictitious claims.  The ex-employee nurse who turned St. Joseph’s in got to split $4.94 million with her lawyer.  My guess is that but for the disgruntled nurse, St. Joseph’s would still be billing the same way and that dozens of hospitals across the nation are doing the same thing right now.

Of course, there are plenty of genuine rip-offs, too.  It will be interesting to see how the suit the Justice Department filed on July 27 plays out.  Dr. Najam Azmat and the Satilla Regional Medical Center in Waycross, Ga., are accused of some nasty business. According to the lawsuit, the hospital recruited Dr. Azmat in 2005 and allowed him to perform procedures he was never qualified to do.  It became obvious to one of the nurses that Azmat didn’t know what he was doing and many of his patients were being injured.  She reported her beliefs to the hospital administration, but the hospital looked the other way and, of course, kept billing Medicare.  Eventually, word got out after one patient died.  Naturally, the government is tut-tut-ing about these misdeeds:

“When health care providers cut corners by allowing unqualified doctors to perform complicated medical procedures, patients suffer,” said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. “Here, we allege individuals were endangered because of these defendants. The seriousness of this case illustrates why we remain committed to protecting patient safety and the integrity of our federal health care programs by aggressively enforcing our health care fraud laws.”

What will happen is anyone’s guess, but mine is that the hospital will throw Dr. Azmat under the bus and try to settle before some hospital administrator goes to jail.  By the way, these kinds of lawsuits are known as Qui Tam actions.  Qui Tam stands for a Latin phrase that means, “he who brings the action for the King as well as for himself.”  The “King,” if you haven’t already guessed, is good old Uncle Sam.

Glenn L. Goodhart, M.D., J.D.                                    

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