NEW YORK NURSE: October/November 2007
by Mark Genovese
The idea that white-collar crimes are “victimless” is inaccurate, according to Michael C. Clarke, chief of the Medicaid Fraud Unit of the Nassau County district attorney’s office. The victims of healthcare fraud are taxpayers and health insurers, plus individuals and small businesses who struggle to pay insurance premiums.
The Convention endnote presentation given by Clarke and Andrew J. Weiss, special counsel to the New York State Welfare Inspector General, highlighted cases in which RNs helped to catch and convict those who tried to abuse the healthcare financing system.
“Don’t be afraid to report fraud,” Clarke urged. “You have the power to do something about it.” In fact, he noted, fraud must be reported, much like incidents of child abuse and neglect. “It’s a matter of patient safety, your personal reputation, liability, the greater good, and the integrity of the profession,” he said.
Nassau County was the first municipality in the nation to establish a bureau to investigate Medicaid fraud and abuse because financial losses from fraud had led to an upsurge in local taxes.
Clarke and Weiss cited examples of unscrupulous providers and patients who had filed false claims, including overcharging for services provided, billing for services that weren’t provided, ordering unnecessary procedures, or arranging for kickbacks through concealed ownership of related companies.
One case involved a healthcare provider who claimed reimbursement for transportation when the patient actually had used the taxi ride to go shopping. In another, a provider charged Medicaid for artwork and furnishings for his house. Each case was discovered by employees during routine checks of records.
Clark urged RNs to expand their personal definition of fraud and abuse to include the theft of medications. “Most of you don’t go into this profession to steal,” he said. “You’re not doing it for the money or glory, but because it has to be done. Unfortunately there are those who don’t see it your way.”
At one nursing home, for example, the first indication of a problem was a patient’s worsening condition. The patient reported her pain medication was no longer working well. An alert RN discovered holes in the patient’s fentanyl patches. An investigation revealed that an addicted worker was using a straw to sip the drug out of the patches.
This type of theft means patients suffer because they don’t receive the level of medications they need, while insurers pay for treatment that is not delivered. In another case, an RN stole more than 800 doses of pain medication from her facility, using her own PIN and falsifying records of distribution to patients.
Other investigations uncovered prosecutable irregularities such as healthcare staff bringing their own medications to work to sedate patients.
“Your observations from the trenches – whether it’s in administrative offices or in practice settings – are invaluable,” Clarke said.
“We need your expertise to know what’s going on out there,” Weiss added. “We can’t do our jobs without you.”