Over 120 members of Birmingham’s medical community came to the Carraway-Davie House in early November to hear U.S. Attorney Alice Martin speak about healthcare fraud. The luncheon, sponsored by the Birmingham Medical News, was an opportunity to thank the advertisers, physicians, healthcare administrators, and medical writers who support the paper, according to Steve Spencer, BMN publisher. “The people who read and write our paper, who provide us information, and who take time for interviews are as critical to the success of the newspaper as our advertisers. It seems appropriate to take the time once a year to say thanks to all of them for their help and support,” he said. After convening the luncheon, Spencer introduced Martin, who discussed healthcare fraud and prosecution. Martin said that prosecuting healthcare fraud is a “low-risk, high-return investment,” and she added this caution: “Disgruntled employees are our best source of information. Think about that at Christmas bonus time,” she said with a laugh. With $4.8 billion spent in Alabama on Medicare in 2006, and $4.2 billion on Medicaid, there’s tremendous taxpayer money at stake, she pointed out. Since the government gets back $5 on every $1 spent on prosecution, healthcare fraud is worth investigating and prosecuting. Martin explained that investigations can be initiated from a variety of sources: anonymous tips, intermediary (Medicare Part A) or carrier (Medicare Part B) referrals, private insurance referrals, and qui-tam (or whistleblower) lawsuits. Her office was alerted to one case by the business manager at a practice who suspected a doctor of improperly billing for patients he never saw. A private insurance company provided a tip on another case when they didn’t understand how a psychologist could possibly be seeing so many patients in one nursing home. He was reporting 40 cases per day, although they discovered he was not even going to the nursing home. A drug company turned in another doctor for submitting cases for a study. Her numbers were off the scale higher than those for much larger practices, and they became suspicious. Martin stressed that intent to defraud is an important factor in the decision to prosecute and what penalty to try for. “We have had people self report,” she said. “It may be a case where an employee leaves and someone new has come in.” The new employee may discover that the practice has been doing something improperly. Often there’s no intent to do wrong, but simply a process that needs adjusting. In these cases, Martin suggested that self-reporting is the best recourse. “If we find out later and you’ve concealed it, we’ll go for treble fines. “People make mistakes. Sometimes we just want to recoupe the overpayment and let it go. We don’t make a big deal about it.” In fact, she says she’s never held a press conference on a case that was self-reported. “If it is an honest, or even a careless mistake, we’ve never tried to hammer down. The majority of our fraud cases are against physicians who you, too, would want to prosecute,” Martin said. “They’re performing as thieves with physician licenses.” December 2007