HCR 460: Investigations and Disclosures in Health Care Compliance

            When it comes to whistleblowers, keeping them protected is vital not only for them but also for future whistleblowers. Because of whistleblowers, businesses can either fix themselves before they fall completely, or the justice system can take down major companies that are committing major violations and dangers (knowingly) when it comes to patient care. Today’s focus will be on Tarrant County’s John Peter Smith Hospital (JPS) and its violation of the False Claims Act (DOJ. 2021.). The whistleblower filed a suit in 2018 by the Director of Compliance Erma Lee (DOJ. 2021.). The complaint includes information about how the JPS hospital improperly used appended billing modifiers -25, -59, and -XU (DOJ. 2021.).

            The investigator can ask for files on specified patients that are part of the improper billing and coding issues, documents from the billing and coding department, and documents from the accounting and financial departments as well. This will help gain evidence and prove that the JPS hospital did indeed commit against the False Claims Act. The investigator can also ask for documents from the specified insurance companies as well to see what was filed and how it was all filed. The government-based organizations may also step in and perform their own investigations on the JPS hospital to help get into more depth when it comes to the government insurance organizations. According to the whistleblower, JPS hospital had committed between 70% - 90% of improperly using the specified modifiers (DOJ. 2021.).

            Ms. Lee amended her original complaint in September 2020 which added about how she did alert the hospital leadership on these claims (DOJ. 2021.). She also mentioned how JPS Hospital failed to reimburse the payors when they overpaid due to improper coding claims (DOJ. 2021.). Reimbursement is supposed to happen when a patient overpays for a service but there are some companies who do use the extra payments as credits. I personally like the credit option because I don’t know if I will have money for my visit in the future or not.

            Fortunately, whistleblowers are protected from retaliation thanks to the Whistleblower Protection Act of 1989 (HHS, et. al., n.d.). There are two criteria that a person must follow in order for the Whistleblower Protection Act of 1989 will take into effect. First, the report must be based on a reasonable belief of wrongdoing (HHS et al., n.d.). Secondly and lastly, the complaint must be made in person or by an authorized person (HHS et al., n.d.). There are limitations as to who can and can’t create reports for the OIG (HHS et al., n.d.).

            When retaliation does occur due to creating a whistleblower complaint, there is a way to file the retaliation thanks to the OSHA Fact Sheet information provided. What is defined as retaliation? Retaliation is the following, but not limited to, firing, or laying off, demotion, reduced working hours, denying promotion and overtime, denying benefits, intimidation, making threats, failing to hire (or rehire), etc. (OSHA. 2014.). There is a list of noncovered provisions for the whistleblower which is the Medicare and Medicaid Fraud and Patient Abuse (OSHA. 2014.). There are limits to everything because not everything can be protected, nor should everything be reported unless it’s legitimate.

            However, if there is retaliation found, the employer must pay the whistleblower the lost wages, restore all benefits applicable, and allow them to get back to work (OSHA. 2014.). If the whistleblower’s complaint is not supported by sufficient evidence, OSHA will then disregard the complaint (OSHA. 2014.). The written complaints can be sent in writing via fax, electronically, hand delivery, or U.S. mailing and they may even be sent to a local OSHA office (OSHA. 2014.). OSHA will review the complaint accordingly and determine if it meets specific requirements as noted on the website (OSHA. 2014.). These are all reasonable rules and regulations as not all complaints are legitimate nor do all complaints follow the correct specified requirements as noted by the OIG and OSHA.

Resources

·      Department of Justice, Northern District of Texans. 2021, August 27. Hospital to Pay More than $3 Million to Settle Whistleblower Suit. Retrieved from https://www.justice.gov/usao-ndtx/pr/hospital-pay-more-3-million-settle-whistleblower-suit

·      U.S. Department of Health and Human Services (HHS) & Office of Inspector General (OIG). N.d. Whistleblower Protection Information. Retrieved from https://oig.hhs.gov/fraud/report-fraud/whistleblower/

·      Occupational Safety and Health Administration (OSHA). 2014, January. Filing Whistleblower Complaints Under the Affordable Care Act. Retrieved from https://www.osha.gov/sites/default/files/publications/OSHAFS-3641.pdf