Politics and fraud prevention make an ugly partnership


Editor's Corner



In reading the Wall Street Journal's investigative piece about how politicians influence Medicare fraud investigations, I walked away with two conflicting reactions.

The jaded, cynical side of me was not particularly surprised. Politicians push their weight around in nearly every corner of government--and that weight is often padded with money from special interests. Why would fraud prevention be any different?

But another side of me was at least taken aback, if not slightly shocked, by the details uncovered. The direct contact between state representatives and Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner was unsettling, particularly when you look at how fraud investigations were altered after that communication took place.

The WSJ describes two separate instances in which Tavenner was contacted by politicians. Perhaps the more egregious one involves Rep. Sheila Jackson Lee (D-Texas), who contacted Tavenner in 2012 regarding an investigation into Houston's Riverside General Hospital in which Medicare claims were filed for patients who weren't treated. This was in the wake of a separate case involving the hospital's assistant administrator, Mohammad Khan, who pleaded guilty to a $116 million Medicare fraud scheme involving false claims for mental health treatment.

Weeks after that communication, payments were restored, even though the hospital remained in the midst of a criminal investigation. Two months later, federal officials arrested Riverside CEO Earnest Gibson III on healthcare fraud charges. In October, Gibson and three others were convicted for the very same scheme for which Khan pleaded guilty two years prior.

Jackson Lee's connection to Riverside runs even deeper. Her husband, Elwyn Lee, once served on the hospital board as the president and vice-president. Riverside has its own checkered history, too, littered with fraud allegations, state actions and even disturbing structural deficiencies. In 2004, the state moved most of its drug treatment contracts to other providers amid allegations the hospital was padding its billing and fees. Jackson Lee demanded Gov. Rick Perry (R-Texas) investigate and restore the money, and Riverside came out $3 million on top. In August, the hospital surrendered its substance abuse treatment license

The WSJ details another instance in which Gov. Rick Scott (R-Florida)--who has had his own brushes with Medicare fraud--helped facilitate a meeting with the owner of two nursing homes and Tavenner regarding payments that had been partially blocked as part of an investigation of suspicious billing. Weeks later, those payments were released.

Politicians have a duty to protect the healthcare institutions in their jurisdiction, many of which provide necessary services to the community--not to mention hundreds, if not thousands, of jobs. Ensuring that underserved populations have access to viable healthcare options is an important and necessary endeavor. In her letter to CMS, Jackson Lee emphasized that the sanctions against Riverside would "jeopardize" patients needing Medicare and harm "the most vulnerable patients."

However, elected state representatives also have an obligation to taxpayers. When they meddle with legitimate fraud investigations, they do a disservice to the very people who elected them, allowing their own constituents to be robbed. Applying political pressure to impede fraud investigations is like holding the door for the bank robber on his way out.

For politicians, the desire to provide accessible and affordable healthcare may, at times, be at odds with fraud prevention efforts. However, we often hear politicians shout strong, authoritative verbiage regarding Medicare fraud prevention. Instances such as those described here make those words seem hollow.  

In other cases, it may simply be the result of pressure from lobbyists. When healthcare associations are active campaign contributors, the lines of fraud enforcement and special interests are significantly blurred.

More importantly, when politicians can whisper in the ear of the top CMS brass, and fraud investigations and sanctions are actively tampered with, those lines are virtually non-existent. - Evan (@HealthPayer)