Health care providers that use fraudulent billing practices can cost Medicaid, Medicare and private health insurers and private long-term care insurers dearly -- and, in some cases, interfere with quality of care patients receive.
Two subcommittees at the House Oversight and Government Affairs Committee looked at the effect of provider fraud on a Medicaid patient during a joint hearing convened Wednesday (see video).
Lawmakers heard from Richard West, a New Jersey resident who helped blow the whistle on Medicaid fraud that affected his own health care by filing a "qui tam" lawsuit under the federal False Claims Act (FCA). The suit eventually led to a home health care provider payinga $130 million civil settlement and $30 million in criminal fines, West testified, according to a written version of his testimony posted on the committee website.
West qualifies for Medicaid help with paying for 16 hours of in-home nursing care per day because he has trouble with very basic activities of daily living (ADL), such as breathing. He depends on both a wheelchair and a ventilator.
In 2004, because, it was later discovered, the provider had been overbilling Medicaid, a state agency told West had exceeded his monthly benefit cap, and that his Medicaid services were being reduced or suspended as a result.
"This preventedme from obtaining needed dental care," West said.
Later, West said, after he complained about what he was sure was a billing problem, he filed a complaint with state officials and hired a lawyer.
After that, he said, he had trouble getting home health care nurses to come to his house, even when he had a serious viral infection.
"Somebody decided to make a profit on my disability and rip off the government," West said. "That was wrong, and the right thing for me to do was to expose it."
FCA suit rules require a plaintiff to give investigators all available information at the time the suit is filed and put any proceedings under seal. The plaintiffs
West said that, because he could not talk about the case and explain his side, he felt as if he had gotten a reputation as a troublemaker, and that was interfering with his access to care.
Another witness, Gary Cantrell, assistant inspector general for investigations at the U.S. Department of Health and Human Services Office of Inspector General, said the West case is an example of a recent increase in fraud cases involving home health and personal care providers.
"We are now seeing more Medicaid fraud cases involving home health services than any other single program area," Cantrell said.
Many of the fraud cases involve billing for the kinds of personal care services provided by unskilled aides who help recipients with ADLs such as bathing and feeding, Cantrell said.