Fraud convictions, false claims settlements and the inner compass


Maybe it's the counselor in me, but I wonder what happens to people and institutions on an inner level after fraud convictions or false claims settlements. Have those involved changed after their scrapes with the law? What have they learned, and what are the takeaways for fraud fighters who study their cases?

Tara Shameed Wright, owner of a medical company providing services to mentally disabled adults, pleaded guilty to healthcare fraud after cheating Medicaid out of $450,000, The Roanoke Times reported. Prosecutors offered evidence of falsified patient records and time cards. Wright was previously banned from federal programs after being convicted of financial aid fraud in connection with student loans, the newspaper noted.

In another repeat offenses case, an imprisoned Pennsylvania doctor will plead guilty to healthcare fraud, according to the Associated Press. Oliver Herndon, M.D. went to prison after supplying so many illegal narcotics that his arrest caused the street price of pills to double, the AP reported. He was ordered to make restitution of $700,000 to insurers who paid for most of these drugs. Herndon admitted filing hospice claims for patients who weren't terminally ill along with claims for services not rendered. 

In a third case, Dignity Health, a chain of California hospitals built and run by the Roman Catholic Church, agreed to pay the government $37 million to settle whistleblower allegations of overbilling Medicare for high-cost services beneficiaries didn't need. Though the provider didn't admit wrong-doing, Catholic Online sharply criticized the hospital system in the aftermath of the settlement.  

"This is what happens when an institution loses its moral compass," Catholic Online wrote. "This is what happens when a Catholic hospital, which ought to be supervised by the Church, allows secular staff to comprise its board and manage the facility for financial gain. Instead of running the facility for the benefit of people, it is managed for the benefit of profit."

Finally, a man convicted of securities fraud wrote a blog post from prison to warn others against similar missteps. Brian Jorgenson--a father of four--argued that crimes committed by most of his fellow white collar inmates "truly were aberrations in their character" rather than acts defining who they are. Never in a million years did they imagine they would go to prison if caught, Jorgenson wrote. They underestimated the government's prosecutorial zeal and viewed their behavior as a gray area they could explain away later.

Are you sighing with me over these stories?  

Wright's case is another warning that the federal government must close sanction screening loopholes. Using biometric technology is a positive step toward that end. Whenever an excluded individual slips back into government programs to defraud again, it's an incentive for others to try it. Exclusions should exclude; otherwise, they're just wobbly fences.     

Herndon's case is another example of how criminal behavior generalizes, how those who steal from one area are apt to rob another. This shows the need for payers to do ongoing, proactive fraud risk management, to check all possible avenues for signs that criminals may have tapped other service areas or business lines.  

The Dignity and Jorgenson cases apparently involve departure from organizational and personal values. These cases are a reminder that billing errors and fraud are committed by human beings, and human beings can make serious mistakes. But it's possible to begin anew after reflection and reparation, to hold ourselves to higher standards of conduct.  

Maybe it comes down to this: Some people know when they've lost sight of their inner compass and regret veering off course. They're willing to change direction and learn. But for others--the hardened offenders--different priorities have replaced true north. The combination of energy and ambition without integrity creates a significant fraud threat. - Jane (@HealthPayer)   

Related Articles:
CMS unveils provider fingerprinting program
Biometrics take fraud fighting to new frontier
The cautionary tale of Florence Bikundi, an excluded provider
Home care and hospice fraud trends to watch
Call for standardized medical ethics