Siwicki became one of the many Americans who blow the whistle on the illegal activity in the health care system every year.Whistle blowers who come forward and lower the boom on fraudsters are entitled to a financial award for the information they provide. Attorney James D. Young, who represents Siwicki, says like many of the whistle blowers he has represented, financial gain was not her primary motivation.
“I think the money was never the driving force. She just wanted to end this fraudulent practice,” says Young from the all plaintiff firm of Morgan & Morgan in Tampa, Florida.
According to the statement of claim filed first under seal on April 21, 2015 Siwicki was “repeatedly witnessing inappropriate treatment of patients, fraudulent documentation and fraudulent billing” in Dr. Portnow’s practice.
Siwicki saw, according to the documents, “repetitive studies were being ordered when previous test results were normal. In addition, certain ultrasound tests were always performed together regardless of patient need.”
The Florida technician often “spoke to patients who denied having the ailments that Dr. Portnow documented in their medical records”.
Medicare pays for medically necessary ultrasounds under the Social Security Act but, according to the evidence provided in the statement of claim, Dr. Portnow falsified medical records and test results to justify repeat testing.
National health expenditures in the United States reached $3.2 trillion in 2015 and represented 17.8% of the nation’s gross national product (GDP). According to the National Health Care Anti-Fraud Association (NHCAA) the extent of the fraudulent claims are impossible to determine. However, the FBI estimates the cost to be in the billions. The Institute of Medicine of the National Academies estimates health care fraud costs the system about $75 billion a year.
“There are many practitioners and the government can’t watch every single physician and every procedure,” says attorney Young. “They can’t audit every invoice and there is a huge volume of activity. There are a lot of people and a lot of hands on this and it is hard to police.”
Depending on the quality of the information they provide, whistle blowers are entitled to a reward of 10 to 30 percent of the amount authorities recover from health fraud investigations. During the Obama administration whistleblowers in what lawyers called “Qui Tam” investigations received approximately $ 4 billion in financial compensation for the information leading to successful investigations. In some cases, the identity of the whistle blower is never released.
Siwicki’s access to dozens and dozens of fraudulent medical reports and examination records provided her with pristine evidence.
“Sometimes clients will come to us after they have been fired and they won’t have access to records,” says Young. “In this case we had a client who came to us and said there are bad things going on at my physician’s office. She was able to discern proof of the fraud within the records and get copies of them.
“A lot of people are not aware of this but there is actually an exception in the Health Information Privacy (HIP) laws that allows individuals to share otherwise HIP protected information with the government to report fraud or crimes,” add Young.
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Kathleen Siwicki received $351,000 for her information.
Although there is really no such thing as a typical case Siwicki’s story has many of the hallmarks of the average whistleblower case. She was a mid-level employee with access to records and reason to believe there was a problem. Whistle blower cases usually take about 4 years to resolve – this one resolved in just over three years.
James D. Young focuses his practice on working with whistle blowers in the healthcare industry. He has more cases in the pipeline. Morgan & Morgan works exclusively with plaintiffs on a contingency basis. It is the largest plaintiffs only firm in the US with more than 350 lawyers.