The persons to whom we spoke also told us that these deceptions and improprieties became a way of doing business and continued for sustained periods without detection because HCFA, in its review of Medicare contractors, relied on information provided by contractors without independent verification. HCFA also gave contractors advance notice of the files that it intended to review, thereby allowing contractors ample time to "correct," delete, or hide claim-related documents or redo provider audits and related workpapers prior to HCFA's review. This system also resulted in contractors deviating from their normal operating procedures during HCFA evaluations in order to deceive HCFA about their accuracy and efficiency in claims processing and customer service. As a result, criminal and other improper activities were uncovered only after whistleblowers, or relators, filed qui tam complaints under the False Claims Act.
Blue Cross and Blue Shield of Alabama apparently has joined in the questionable activities. A former auditor named Frank E. Body alleged that the company had reimbursed Alabama hospitals for interest costs that were not authorized by Medicare regulations. The U.S. 11th Circuit Court of Appeals ruled that Body's whistleblower complaint must be dismissed on complex immunity grounds. But his complaint provides insight into the culture of Alabama's powerful "Blue."
Here is the gist of Body's allegations:
In August 1993, prior to the issuance of the OIG's final report, Body instituted this lawsuit for the United States as a qui tam relator under the False Claims Act. Body alleges that BCBSA has been reimbursing Alabama hospitals, in particular Baptist and Carraway for interest costs that are not chargeable to Medicare.
By the way, our research indicates that the 11th Circuit's interpretation of immunity issues in the Body case has not been adopted by any other circuit. And the opinion was authored by Gerald Bard Tjoflat, a Republican appointee who was on the three-judge panel that butchered the Don Siegelman appeal. In other words, it appears BSBSA drew favorable judges and got off easy in the Body case.
The GAO report and the Body complaint date back 10 to 20 years. But the recent case in South Carolina indicate that the "Blues" still have significant problems with fraud.
Here's something the town hallers don't care to recognize: History tells us that private insurers are not necessarily part of the solution; they are part of the problem. And if you really want to solve Medicare fraud, you had better not rely on private insurers to do it. In many cases, they are the ones committing the fraud.
1 | 2
