Medicare Compliance & Reimbursement

In some states, whistleblowers can pursue you on state and federal grounds. 

Whistleblowers can be a health care provider's worst nightmare - if they're right about a compliance problem, they've identified in the worst possible way, and if they're wrong, they've created a costly legal hassle that could drag on for years.

And in some states, whistleblowers have more options than others. Eleven states and the District of Columbia currently have their own whistleblower laws that qui tam relators can use in lawsuits against health care providers.

On Nov. 7, a federal court unsealed a case brought under one of those laws - The Texas Medicaid Fraud Prevention Act - that accuses mental health services provider Rescare Inc. and a host of related companies of defrauding Texas' Medicaid program.

The case was filed by Judith Hudnall - who worked for Rescare subsidiary The Citadel Group for less than a month in 2000 - and joined by the state of Texas this month. It charges the defendants with billing for mental health services that were unnecessary or never provided, altering treatment plans to ensure Medicaid beneficiaries would remain eligible for reimbursement and billing for non-reimbursable services. It's the first whistleblower suit the state of Texas has joined against a mental health services provider, according to Hudnall's attorneys.

"This case demonstrates that the growing number of State False Claims Acts can and will play an active and prominent role in future efforts to combat fraud," says Hudnall's lead trial counsel Marc Raspanti with Miller, Alfano & Raspanti in Philadelphia.

Lesson Learned: The growing arsenal of legal weapons available to would be whistleblowers makes a robust compliance program more important than ever for health care providers.