It's one of the state's largest ever Medicaid fraud cases.

In a complaint filed in state Circuit Court on Tuesday, state Attorney General Douglas Chin said Liberty Dialysis overbilled the state Medicaid program more than $7 million over a five-year period. Chin's suit seeks another $20 million in damages because the alleged overbilling was intentional.

"What we're alleging is that Liberty Dialysis was gaming the system," he said. "They were aware that at a certain period of time, they would be overbilling the state and at the same time they continued to submit false claims."

The state filed the lawsuit after an administrative hearings officer on Friday ruled that Liberty must pay back the state the $7 million. Besides damages, the Circuit Court lawsuit also seeks fines of up to $11,000 for each false claim.

The alleged overbilling was for the drug Epogen, which is used to treat anemia in people with renal failure. The state said that Liberty often billed patients for multiple doses when administering just one dose.

"In asking for this lawsuit, we're looking potentially at tens of millions of dollars in damages," Chin said.

A spokesman for Liberty offered the following response in an email: "We intend to appeal the State hearing officer's decision, and strongly disagree with the assertions contained in the Attorney General's lawsuit."

Copyright 2015 Hawaii News Now. All rights reserved.
 

...

Lorin Eleni Gill

Hawaii Attorney General Doug Chin said the state has filed a second lawsuit against… more

Liberty Dialysis is being ordered to pay $7 million in overpayments to the state of Hawaii, which has filed a second false claims lawsuit against the dialysis provider, the state attorney general’s office said Wednesday.

The $7 million reimbursement was awarded to the state to cover overpayments to the company between 2006 and 2010 for Liberty's Medicaid patients.

A computer error in the state Department of Human Services claims processing system led to the original overpayments.

The new lawsuit, filed Tuesday, alleges that Liberty knowingly exaggerated claims for a drug, despite an alert from a billing consultant.

Receive Pacific Business News's Morning Edition and Afternoon Edition newsletters and breaking news alerts.

Upcoming Events

“We expect to prove in this new lawsuit that Liberty gamed the system to keep being overpaid,” Attorney General Doug Chin said in a statement. “We will not and cannot tolerate this kind of behavior.”

The lawsuit alleges reimbursement requests were inflated for a drug called Epogen, which is used during dialysis treatment.

The complaint asserts intentional and negligent misrepresentation, unjust enrichment, and that a breach of contract took place.

The state will seek triple damages for the overpayment plus civil penalties of $5,500 to $11,000 for each false claim submitted, as well as attorney fees and costs.

Want Honolulu Health Care news in your inbox?
Sign up for our free email newsletters.

Suggested Reading

...

“We expected to be rounding on you yesterday, too.”

The tone of the comment was jovial and the intention behind it lighthearted when a senior physician at my previous job said those words to me a few years ago. Nonetheless, the message was clear enough. I had called in sick the day before, and the implication being made was that presumably I only would have done so if I had been nearly ill enough to need hospitalization myself.

Medical providers routinely tell our patients to stay home when they are sick. But when it comes to providers ourselves, we all too often choose otherwise.

A new study in the journal JAMA Pediatrics examines why physicians and nurse practitioners head to work when they are symptomatic, despite knowing they might risk spreading their illness to others. And man, could I relate to what they said.

Researchers sent a survey to all attending physicians and advanced practice clinicians—including certified registered nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives—at The Children’s Hospital of Philadelphia (CHOP), one of the nation’s premier children’s hospitals. Of the approximately 60 percent of providers who responded, about 83 percent reported working while suffering from some kind of illness at least once in the past year. A little over nine percent reported doing so five times or more. This despite over 95 percent of respondents acknowledging that working while sick puts patients at risk.

Of the approximately 60 percent of providers who responded, about 83 percent reported working while suffering from some kind of illness at least once in the past year.

Among the most common reasons cited for showing up with symptoms, nearly everyone who answered listed not wanting to let colleagues down. Right behind were fears that there wouldn’t be sufficient staff to see patients and not wanting to let those patients down, either. To my dismay but not my surprise, nearly two thirds reported fear of being ostracized for staying home sick.

It’s all too understandable how these patterns of behavior come to pass. Medicine is a profession that puts a premium on overachievement. Anything that gives the appearance of working less hard or striving less diligently than one’s peers is anathema. It doesn’t matter if you’re sick or not, the patients are going to need seeing. If you’re not there, it just means you’re making the people around you work harder.

The more limited the available staff in any given clinic or department, the worse the problem will be. At a world-renowned institution like CHOP, patients may have been waiting months to see a particular specialist. It was no surprise at all to read that providers there described trying to find back-up when they were sick as “a disaster,” “a nightmare,” “impossible,” “chaos,” and “brutal.”

“I think hospitals and emergency departments are a little different than private offices, as EDs can't close,” Dr. Emily Martin, a pediatric emergency medicine specialist at a large academic medical center, wrote to me. (Given the sensitive nature of the topic, all people I spoke to requested I take steps to prevent their being identified. Names have been changed here and below.) “We do our best to get coverage. With staffing at a minimum, we're often stuck working when we shouldn't. Though, the hospital policy clearly states ‘don't work with a fever.’”

“What I hate is the policy of ‘don't do it,’ but there’s no system in place to help prevent it,” Dr. Martin continued. She notes that the hospital can’t pull providers from a specialty like nephrology to cover the ED (or visa versa) because of the different kinds of expertise needed in the different departments. Because of staffing pressures like this, another doctor I heard from spoke of giving ED providers IV fluids before sending them out to finish a shift.

I wish that struck me as shocking, but as someone who completed a night of call as a senior resident with an IV himself, it simply sounded familiar.

What sets this new study apart is that it examined the behavior of doctors and other clinicians who were out of training. Other studies have dealt with the problem of “presenteeism” among resident physicians, on whom the pressures are even worse. A physician in Canada told me that over a holiday call cycle she worked sick as a resident because the other resident sharing back-to-back call with her would otherwise have had to work three days in a row.

However, as well-documented as the time demands on residents are, this new report shows that more senior medical providers are no less prone to work sick than those in training. A 2010 study of residents across numerous specialties found that nearly 60 percent had worked while ill within the previous year, which is still far too many but much fewer than the 83 percent of attendings and other clinicians surveyed at CHOP. (One hospital in that study did report a startling 100 percent rate of residents working while sick, which I do not take as a positive comment on the culture there.)

Because of staffing pressures like this, another doctor I heard from spoke of giving ED providers IV fluids before sending them out to finish a shift.

Of course, the pressure to work when sick isn’t limited to physicians and other clinicians. Nurses face similar pressures, both from peers and supervisors. In some cases, the decision to work sick is a result of hospital policies.

“I work with plenty of doctors and nurses who go to work sick,” I was told by Allison Stevens, a nurse in New Jersey. “Myself included. If we call out, we use paid time off or vacation time.”

She says that the hospital where she works cut sick days, and that promised additions to paid days off never materialized.

“We view it as a punishment from the hospital to be sick and use [vacation] time,” she continued. “The nurses I work with hate the policy. We used to accrue sick time up to around 960 hours, and the hospital took it away as an incentive for people to not call out. So now we go in sick.”

It doesn’t seem to require a flying leap of logic to conclude that a policy meant to discourage employees calling in sick will create a disincentive for them to stay home when they ought to.

To some extent, the problems that lead to inappropriate presenteeism are difficult to fix. A hospital cannot hire such a plenitude of providers that there will always be ample coverage for all its departments all the time. If it means choosing between exposing a patient to an illness they suspect is mild and low-risk vs. cancelling and trying to reschedule a long-awaited appointment, many providers are probably going to opt for the former.

However, the stigma attached to staying home except when you’re at death’s door has got to go. We owe it to our patients to diminish their risk of catching additional illnesses from us when they come to us for care. Working harder when we must to pick up the slack when the provider staff is stretched is something that comes with the job, and freedom to stay home ourselves when we shouldn’t be getting out of bed is a reciprocal part of the bargain.

If we’d tell your patient to stay home from school or work with the symptoms we have, we have an obligation to them to heed our own advice. Nobody should fear repercussions for doing so.

...

Alberta’s Minister of Health Sarah Hoffman says she’s gained a first-hand understanding of some of the Lac La Biche area’s healthcare challenges that will factor into decision-making further down the road.

“I’ve been on the job for a couple of months now and I definitely am aware of some of the struggles here,” Hoffman said. “Unfortunately, there are struggles in a variety of areas in Alberta.”

Hoffman paid a visit to the William J. Cadzow Healthcare Centre last Tuesday. Along with hospital officials and local dignitaries, the minister toured the hospital and the dialysis bus that’s been parked outside for the past three years—and caused no small amount of consternation in the community in that time.

“It’s clearly not an ideal situation,” Hoffman said after boarding the bus to see its inner workings for herself.

Meeting of the minds

Before being shown around the facility, the minister met with hospital administrators, local politicians and MLA David Hanson. Mayor Omer Moghrabi credits Hanson with being the driving force behind the rendezvous.

“I’m incredibly impressed that we had her show up this soon,” Hanson said. “I pushed it pretty hard in the Legislature and obviously it didn’t fall on deaf ears.”

During the meeting, Moghrabi and Deputy Mayor John Nowak each spoke about the Lac La Biche hospital’s ongoing quest to become a regional hub for medical services, complete with a proper dialysis unit and a full range of diagnostics services.

The mayor says the local hospital already plays the part of medical hub for the region, since the next-closest healthcare facilities are all long distances away.

“This is the centre of (Alberta Health Services) Zone 7 and I think they understand that,” Moghrabi said. “They were nodding their heads (during the meeting).”

Hanson says that, with notorious highways like 63 and 881 running through the region, Lac La Biche’s healthcare centre needs to be ready and able to handle serious cases.

“It’s a hub for northern Alberta. It’s very important that we maintain it. We need to make sure that Lac La Biche is prepared for anything that might happen,” the MLA said. “I support any expansion that we can see, especially in the Lac La Biche area.”

Hoffman says she didn’t mind visiting Lac La Biche at Hanson’s urging, even though the community is situated in a Wildrose Party-held riding.

“I’m responsible for healthcare for all Albertans and when I know there’s a healthcare need in a community, I want to have an opportunity to gain a greater understanding and address it moving forward,” she said. “We’re doing this tour (of healthcare facilities) throughout Alberta. We’re connecting with communities and I’m really proud that this is one of our early stops. There’s good work happening all over the province and there’s needs all over the province and I think it’s important that we have a government that’s in touch and aware of that.”

While the meeting and tour concentrated on healthcare concerns and shortcomings, like the dialysis bus, there were more positive moments as well, the minister says.

“We got to meet some staff who have been here for 25 years and some who have been here less than five,” said Hoffman. “It’s neat to see the mix and how many professionals are attracted to work in Lac La Biche. The rate of physician recruitment and retention does not seem to be a problem here. You don’t always hear that in rural Alberta.”

Dialysis concerns

The dialysis bus is one of the hospital features that stakeholders near and far are keen to see improved. Lac La Biche County Council has been vocal in lobbying for improvements to the bus, especially in recent months as more and more problems with it have emerged.

Accessibility is one problem. Reliability is another. Several weeks ago, ongoing maintenance resulted in the bus’ water supply running low during a dialysis session. The cramped bus has also had its share of mechanical problems, some of which have required patients to seek treatment elsewhere.

The bus was introduced in 2010, after a heavy lobbying effort on the community’s part. Originally, it was a “mobile dialysis unit,” roving between communities in northeastern Alberta, but it was permanently parked in Lac La Biche in 2012.

Hoffman says she realizes the bus is a bandage solution, but decisions on where to build new infrastructure will be made based on statistical evidence as well as her first-hand looks at challenges.

“This is some of the qualitative evidence, being able to see and experience and get to know some of the patients and the staff working,” she said. “Also we need to look at some of the numbers, what the demand is in different parts of the province. I’m really happy that the five spaces that are here on the bus currently are an adequate number of spaces to meet the needs of the dialysis patients living in the area. I definitely appreciate the thorough conversation and the information that was provided.”

Rolling on forward

Moghrabi says he and other County officials intend to keep pushing for an indoor, full-time dialysis unit.

“This is a hospital. It deserves a permanent structure,” he said. “If you have the will to do something, you can get it done,” he added, noting that it might yet take some time for a better solution to be arrived at. “I think they’ve heard us. We’ve gotten into a better position now. Really, it’s still going to take a year and a half to two years and I’m being optimistic.”

Hanson says the bus won’t be viable even as a bandage solution forever, so the government needs to take a longer-term approach to regional healthcare delivery.

“Something has to be done, so we might as well have a permanent solution,” he said.

Hoffman says Alberta Health is working on creating a comprehensive capital plan for building new healthcare infrastructure and installing new equipment across the province. In some ways, the government is catching up and filling in gaps that were left open by the previous government.

“I think that infrastructure and deferred maintenance have been some of the challenges that have been taking a lot of our money that could be focused on other facilities,” she said.

Details on healthcare investments—and how the Lac La Biche community will or won’t benefit from them—should be finalized later in the government’s term.

...