CHS Cites ‘Shifting’ Standards in Fraud Allegation Settlement

Reuben Guttman Articles, Whistleblower News

This interview with Reuben Guttman, who practices law with Guttman, Buschner & Brooks PLLC in Washington DC. and who represented three Plaintiff-Relators in United States ex rel. Doghramji v. Community Health Systems Inc., was conducted by John Commins, Senior Editor with HealthLeaders Media. The interview was published online on August 6, 2014.

An attorney representing one of the whistleblowers alleging that Community Health Systems committed fraud says that as a nation, “we have a healthcare delivery system where doctors and individual decision making, to some degree, have been shoved to the side by corporate managers.”

Community Health Systems, Inc. and federal prosecutors have agreed to a $98.1 million payout to settle system-wide fraud allegations levelled by whistleblowers against the Franklin, TN-based for-profit hospital chain.

While they have agreed on a settlement, CHS and federal prosecutors disagree on what prompted 119 hospitals in the nation’s largest acute care hospital chain to allegedly overbill Medicare, Medicaid, and TRICARE from 2005-2010 for inpatient services for patients who may not have needed to be hospitalized.

CHS Chairman and CEO Wayne T. Smith said the hospital chain was struggling “to operate in a complex and everchanging regulatory environment.”

“The question of when a patient should be admitted to a hospital is, and always has been, a matter of medical judgment by the individual physician responsible for a patient’s care,” Smith said in a media release.

“Unfortunately, shifting and often ambiguous standards make it extremely difficult for physicians and hospitals to consistently comply with the regulations. We are committed to doing our best, despite these challenges. Because this is an industry-wide issue, we hope the government will work to devise sound and reasonable rules for the important decision about whether to admit an individual for inpatient care, and we appreciate the opportunity to engage in meaningful dialogue with the government over these incredibly complicated issues.”

A CHS spokesperson amplified Smith’s point by saying that the shifting standards, “such as the two-midnight rule, which has had numerous updates, clarifications, and additional guidance attached to it since it was issued in August 2013… make it difficult for ALL providers to consistently comply with regulations.”

Federal prosecutors said flatly that the fraud allegations stemmed from a “deliberate corporate-driven scheme.”

“Charging the government for higher-cost inpatient services that patients do not need wastes the country’s healthcare resources,” said Assistant Attorney General Stuart F. Delery for the Justice Department’s Civil Division. “In addition, providing physicians with financial incentives to refer patients compromises medical judgment and risks depriving patients of the most appropriate healthcare available.”

Even though the settlement terms don’t include a guilty plea, Daniel R. Levinson, inspector general of the Department of Health and Human Services said that “in an effort to ensure the company’s fraudulent past is not its future, CHS agreed to a rigorous multi-year Corporate Integrity Agreement requiring that the company commit to compliance with the law.”

CHS had already set aside $102 million to cover the settlements and legal bills.

The settlement also resolves several whistle-blower lawsuits levelled by CHS employees in hospitals in several states. The whistleblowers’ share of the settlement has yet to be determined, DOJ said.

Reuben Guttman, representing whistleblower James Doghramji, MD, a former emergency physician at CHS’s Chestnut Hill Hospital in Philadelphia, spoke with HealthLeaders Media about the settlement. The following is an edited transcript.

HLM: CHS CEO Wayne Smith says that the billing irregularities are due to complex and shifting federal requirements. Do you buy that?

RG: I don’t think he has a legitimate point. This is a company that is crying out for additional scrutiny and oversight and this is a poster child for a Congressional investigation. In theory, doctors are supposed to make decisions.

In practice, people like Mr. Smith and companies like CHS have set up a dynamic where individual patient medical necessity is secondary to marketing and money. We are at a point where we have a healthcare delivery system where doctors and individual decision making to some degree have been shoved to the side by corporate managers.

This is a story about a company that was gobbling up suburban hospitals for no medical rationale. It’s not that they can run them better or that they were providing significant expertise. It was just about extracting cash from the Medicare/Medicaid system.

CHS was designing its admissions criteria on a centralized basis. CHS in Nashville was tracking exactly what was going on in all of these hospitals. They knew the economics at a micro level. I don’t think plausible deniability exists here.

HLM: Do you have a sense of the value of the alleged fraud versus what CHS is paying for?

RG: If you actually look the cash flow for this company, this is a very significant amount of money that they have put off. It is probably not significant in relation to the actual cost to the United States government or individual payers or what the government could extract if they tried the case, but it is a number that pushed the edge of the envelop in terms of paying something that is significant but allows the company to go forward.

The most significant thing about these cases is that they make the wrongdoing to some degree transparent as a catalyst perhaps for Congressional oversight. The reality is that unfortunately, many of these settlements are nothing more than the fee for a license to continue to break the law. What is apparent to us is that a lot of large companies are gaming the system and thinking ‘what is the likelihood of getting caught, and if we get caught what is the penalty?’ The penalty becomes part of the game.

We have to have a penalty system that is hard to calculate in advance and that will make it more difficult. But in reality you have to change the healthcare delivery system in the sense that we rely on the integrity of these types of corporations that have put medical decision making secondary to making money.

You can see when a train wreck is about to occur when you look at the debt service for a company. You are not going to create additional sick people. There are only a certain number of sick people. This is a situation that is going to be ripe for fraud.

HLM: Was there a smoking gun for prosecutors or whistleblowers in this case?

RG: In all of these cases, the complexity of the cases, you don’t find smoking guns. It requires you to find the smoke and the pieces to the gun and put it all together. Then, the trick for somebody who is doing lots of fraud cases is to look at the facts that aren’t there, or the rules that don’t exist, or to see what appears to be facially neutral practices are driving impropriety.

For example, if you have an innocuous practice that says when somebody comes into an emergency room and there is a rule that says they should be put on an IV, you can look at that and say that is not a smoking gun, putting someone on an IV.

But wait a second, when you put someone on an IV that means you are going to streamline them into an admissions situation as opposed to giving them bottles of water, maybe they will be OK, and we will send them home. You have to look at facially neutral practices and how they are driving an unlawful result. That is the trick to uncovering fraud. It’s extraordinarily complicated.

You have two things that are going on. One is you have companies engaged in these facially neutral practices that have an unlawful result for the purpose of deceiving regulators. Two, more significantly, it is a way of creating a cult and convincing people internally that they don’t have to worry about it because nobody internally is putting the pieces together. People who are paid well generally don’t want to do it.

This is the simple question you need to ask: What person or entity knowingly exposes somebody to infectious diseases in order to make a buck? That is the cutting question, because the reality is that while hospitals are places to get well they are also places that are dangerous because there are infectious diseases in hospitals. You don’t want to admit somebody unless it is medically necessary.

There are corporate executives who are knowingly and recklessly putting people at risk. That is unconscionable.

HLM: Do you feel this is a fairly widespread practice in the hospital sector?

RG: I wouldn’t be surprised.

A CHS spokesperson reached for comment late Tuesday said “This investigation was not about the quality of care provided or the location of the care that was provided for any patient–or even how long patients were in the hospital. It is about whether the hospital could rely on the physician’s signed orders in the medical chart to establish the patient status as inpatient–and then bill for the exact care that was provided. It is about the “status” of the patient–inpatient or observation–while that patient was in the hospital.

Does Government Really Have the Watchful Eyes to Privatize?

Reuben Guttman Articles, Whistleblowers Blog

Certain things in life are predictable. A kid tilts the gumball machine when the candy does not roll out. A soda machine is kicked when the pop gets stuck. A baseball manager is fired when a team fails to make the playoffs. And, oh yes, don’t forget this one: politicians threaten to give away government functions when they do not work right. In recent days, with word of veterans waiting in line to get health care services, the big boys on Capitol Hill were once again doing their own form of “soda machine kicking” with calls for the privatization of Veterans Administration Health care services.

The rational for outcries to privatize are traced to the purported justification that the private sector is more efficient and works better than government. Really? Do the names Tyco, WorldCom, Enron, and, more recently, General Motors mean anything? What about the hospital chains like Hospital Corporation of America or the drug companies like Pfizer, GlaxoSmithKline, Abbott, and Amgen that over the years engaged in conduct that drew the ire of the Department of Justice?

Setting aside the list of bad actors that could fill a few notebooks, maybe there is something to be said about the idea that the private sector does it better. But is that really true when the private sector contracts with the government, or is a government contract merely a license to steal? Consider this: once government services are contracted out and long term civil service employees are displaced with contractors, there is – as Eddie Murphy might say – “no going back.” And some contractors have such a grip on their relationship with government agencies, it is virtually impossible for the government to keep them in line through any form of adult supervision. Take the case of Lockheed Martin Corporation. It has approximately $37 billion in government contracts currently. In other words, at the same time the United States Department of Justice is pursing Lockheed for violations of the False Claims Act, it is rewarding it with hundreds of millions of dollars in government contracts.

No doubt it is unrealistic to advocate for the elimination of all government contracts. It is, however, reasonable to explore their extent and focus on means to hold contractors accountable. So let’s focus on their extent. Most Americans do not know that government contractors have been hired by agencies to provide guidance on the drafting of regulations that have the force and effect of law. Presumably when this occurs the government is monitoring these contractors for potential conflicts of interest. But sometimes things fall through the cracks, like when the Nuclear Regulatory Commission retained SAIC to work on a rule governing the “free release” into commerce of recycled radioactive metal. It turns out that the NRC did not realize that its trusted advisor stood to benefit from these rules because it had subcontract to aide in the recycling of radioactive nickel from Tennessee’s Oak Ridge K-25 nuclear weapons site. Nor do most Americans realize that the Centers for Medicare Service, a part of the Department of Health and Human Services, actually contracts with insurance companies to dole out government health care dollars. And as to prescription drugs, those insurance companies rely on private “compendia” publishers for guidance on whether the use of drugs for non-FDA-approved purposes is reasonable. Turns out that the compendia publishers rely on committees with doctors who are on the gravy train of the drug companies who stand to benefit from non-FDA-approved use of their drugs.

With all my grousing someone reading this might say “tell it to the judge.” But did I mention that our Supreme Court is pushing to privatize the judicial system through compulsory arbitration. The rent-a-judge movement is no minor anecdote. Arbitrators are not required to adhere to judicial precedent and their opinions — if they even write one — are not subject to review for non-adherence to law.

The privatization of America is a threat to anyone who is not the beneficiary of a government contract. I suppose, of course, that even government contractors have some worry; if they are actually placed in prison for misdeeds they may find themselves under the thoughtful oversight of a private prison company.

All of this goes to the point that on June 20 — at its annual convention in Washington — the American Constitution Society will convene a panel on the “Privatization of America.” It is the first of what will be many much needed dialogues about this subject.

Profiles in Justice: The Art of Labour Relations

Reuben Guttman Articles, Whistleblowers Blog

Trade Union general counsel Maria Ludkin tells Reuben Guttman about the connections between life as an art lawyer and her current role as general counsel of the GMB. This blog written by Reuben Guttman who practices at of Guttman, Buschner & Brooks PLLC and was published in the Global Legal Post on May 12, 2014.

Maria Ludkin knows a lot about art. As counsel to Christie’s for over 12 years, the UK solicitor spent seven years in London as head of litigation and a further five in New York. These days Ludkin is back in the UK – in a different, albeit equally creative role. As General Counsel of the GMB, the UK’s third largest and fastest growing trade union with 635 thousand members, she and her team design campaigns to focus attention on the wages and working conditions for its members who are low wage earners in the public, retail, and utilities sectors. Talking to Ludkin about the GMB’s campaigns, the idea of them being an art form is not so far-fetched. For Ludkin, her artistic “mediums” are the press, the legislature and the courts. She has an acute understanding of how efforts that utilise these three forums lead to results.

Background

Shortly after her graduation from Brunel University with a degree in law and international relations, Ms Ludkin found herself representing 3000 elderly home owners on the verge of losing their homes through mortgage fraud. She orchestrated a media and political strategy that brought her clients relief and led to tightening of UK’s rules governing the selling of endowment securities. This “triumph in the face of a difficult situation” has inspired some of her more recent campaigns.

Private equity campaign

Keeping pace with efforts by multinationals and private equity investors to skim more profits by suppressing wages and eliminating benefits is undoubtedly a challenge which demands creative solutions, much persistence and a solid knowledge of corporate law and finance.

In 2007, Leicester University Professor of Labour Relations Ian Clark worked with Ms Ludkin and Paul Malloney of the GMB on its submission to the Treasury Select Committee inquiry into private equity. In his account of the experience, Clark said that it established that private equity investors often break implicit contracts with the workforce and that “these investors are largely unregulated by the government.” Ms Ludkin added that while private equity investors “may be good for short term investors, it is usually a disaster for employees and the long term health of the company.”

In this campaign, Ms Ludkin broke out of traditional campaigning models and utilised not only press, politicians, and stunts, but also identified activist shareholders whose interests aligned with the campaign and even reached out to rival firms and competitors to comment on her campaign. She successfully had what was usually the opposition press telling her story of cleaners paying more taxes than the private equity partners whose offices they were cleaning. Such tactics ensured that Ludkin won the moral high-ground and successfully brought about changes in regulations of private equity firms.

The Amazon workers

The GMB’s campaign to communicate the plight of Amazon’s 20,000 UK warehouse workers who are paid low wages with minimal benefits is another case in point. “We had to create a visual image of these contract employees who work 10.5 hour shifts walking over 15 miles a day,” says Ms Ludkin. “The warehouses are massive and workers must record fifteen miles on their feet or face termination.”

For Ludkin and her team, focusing on the 15 mile figure was the essential element in creating a visual image of worker mistreatment. “We have an incredible team with incredible researchers and I love it when ideas gel,” says Ludkin. In the case of Amazon, Ludkin’s GMB team wanted to show that workers were “being treated like robots.”

Looking back on her career path, Ludkin reflects that while she “loved working with the extraordinary colleagues in the art world,” she wanted to work on issues with a bigger impact than “just solving rich peoples’ problems.” As for her current work, she points out that “the working poor need good lawyers.”

Tips for lawyers

What advice would this lawyer give other practitioners? Ms Ludkin has the following tips:

• In choosing a practice area, decide what makes you happy, otherwise you will get frustrated and ultimately bored.
• Being able to tell a good story is the key to delivering a message.
• Try to create visual images of the problem and raise issues that will make the listener continue to think about what you said.
• Stretch outside your comfort zone and work with a diverse group of people, not just people like you; the best messages come after testing them out with people who have diverse personalities and skills and sharpening your arguments by listening to people who have completely opposing views to your own.

Benchmarking Law Schools

Reuben Guttman Articles, Whistleblowers Blog

How should law schools be judged? Reuben Guttman questions the current law school rankings and urges law school professors to follow suit.

In the United States, law school deans have now had more than a few weeks to digest the latest rankings by US News and World Report.

Setting aside whatever specific criteria US News employs to rank law schools, by any account the true quality of a law school is a function of only two variables: the students who attend the school and the faculty that does the teaching.

As law schools strive to climb the US News ranks, much attention is given to enrolling students with high college grade point averages and high Law School Admissions Test (LSAT) scores.  These are two of the key criteria that US News factors in its ratings. Curiously, diversity is not one of those criteria and while employment is considered a factor, the specific type of employment is not a consideration in the rankings.

Do these criteria yield those who will have the most potential for being great lawyers, judges, legislators or scholars?  Who knows?  They are simply the criteria that US News analyzes when it ranks law schools.  By this standard a student with a near perfect grade point average who never took a single math or science course would be favored for admission over a chemical engineering major with a B or B plus average.  Or the criteria might favor a student with a near perfect undergraduate grade point average who never learned to write.

The larger point is that a third party – a publication whose interest is in generating advertising revenue and not in the first instance producing great legal minds – is influencing who will be the next generation of judges, advocates for those who cannot advocate for themselves, and counsel who advise multinationals on regulatory compliance.  Really?  A third party is affecting the choice of individuals who will determine how our world will be governed and compliance enforced.

Does this make sense?  In an era where legal interpretation often depends on mathematical or scientific analysis, do we really want to overlook students who endured the rigors of an undergraduate math and science education at the cost of a perfect GPA?  Do we want to place inordinate value on test scores as an indicator of the ability to write coherently or to assimilate information and express a view?  These days admissions officers use these criteria – with unwavering allegiance – simply because they are the criteria established by US News and not necessarily – at least in the first instance – because it is the only way to find students with potential.

While these criteria could very well be an indicator for potential as a great legal mind, the unwavering use of the criteria simply to achieve a for-profit publication’s approval undoubtedly hamstrings admissions officers in selecting entrants to the legal professions that may have valuable skills.

As to the faculty, US News appears to put some premium on scholarship.  This means law schools are urged to hire those teachers that publish.  But publish what?  Do faculties of law schools have to publish books and articles that are useful to practitioners, judges, or legislators or, at least, indirectly impact the lives of people?  No.  They just have to publish.  And as they are urged to publish, they strive to publish about things that no one has written about.  Consider these articles: Postmodernism and Dworkin: The View from Half-Court, 17 Nova L. Rev. 799 (1993); South Park & The Law, 14 Tex. Rev. Ent. & Sports L. 47 (2012); Professor Kingsfield: The Most Misunderstood Character in Literature, 33 Hofstra L. Rev. 955 (2005); and Capital: Conferring with the Flowers: History and Class Consciousness in L. Frank Baum’s Land of Oz, a General Theory of Magic and Law, 20 S. Cal. Interdis. L. J. 67 (2010).

Does the focus on the esoteric advance the profession or prepare students for the practice?  Even Justice Roberts recognizes the irrelevance of this type of scholarship.  During the Fourth Circuit Judicial Conference, Justice Roberts stated, “If the academy wants to deal with the legal issues at a particularly abstract, philosophical level, that’s great and that’s their business, but they shouldn’t expect that it would be of any particular help or even interest to the members of the practice of the bar or judges.”

Somewhere there must be a group of law professors and Deans who are willing to blow the whistle and say the system needs to change.  Maybe at least someone will take the hint.

The Corporate Magician

Reuben Guttman Articles, Whistleblowers Blog

Cosying up to NGOs is just one of the corporate tricks used by big business to distract from problems.

The Washington Capitals recently faced off in a National Hockey League contest against the New York Rangers. Amidst the fanfare of a stadium packed with more than 20,000 fans, during breaks in the action the jumbotron hanging above centre ice flashed season highlights. Curiously, the highlights included not just slick passing and scoring plays but fights. Why was this curious? Well, the National Hockey League at least hints that it is trying to crack down on fighting. But how serious is the NHL when team highlight reels tout fighting? It turns out that the League’s rules outline various penalties for fighting, but nowhere – at least I cannot find it – do the rules say that the league does not condone fighting or that fighting is not part of hockey. The truth is that while the NHL packs its arenas with people who want to see fights, it struggles from a public relations perspective to guard against criticism that hockey is a violent sport; hence the purported rules that create the illusion of addressing these concerns. Remember the old joke, “I went to a fight and a hockey game broke out.” As an aside, this is a shame because ice hockey – without the fights – is quite glorious.

Masters of illusion

The point is that professional hockey is a business. These days big business is the master of illusion; focusing attention on benevolent activity as a distraction from conduct that is problematic from a legal or public relations vantage point. Take the case of Wal-Mart and the Walton family which created the company and owns the majority of its shares. The Walton Family Foundation has given millions to the Environmental Defense Fund, a US based environmental NGO, which in turn has praised Wal-Mart for being a “green company.” At the same time Wal-Mart is winning accolades for its greenness, it is being pursued by the United States Department of Justice and various State Attorneys Generals for violations of the US Clean Water Act. Embracing NGOs that perhaps were at one time corporate critics is just one facet of the illusion game.

What about companies that tout job safety but continue to place workers at peril? Do they really favour safe workplaces or do they just want to focus attention away from that which is problematic? Or what about the big pharmaceutical companies which have, in recent years, pleaded guilty to violations of the US Food Drug and Cosmetics Act for marketing derelictions? No doubt each of these companies had internal compliance programmes and explicit rules proscribing that which lead to guilty pleas. In almost all cases employees were made to sit through training sessions where the rules were purportedly taught. Yet, at the end of the day, were these programmes really meant to deter wrongful conduct or were they really designed to focus attention away from wrongful activity? Were they just a clever means of convincing employees that scrutiny of corporate conduct is pointless because wrongdoing is not possible for a company with rules that proscribe bad acts?

The illusion game is big business and no doubt there are consultants who have given serious thought to that which I write about here. Cozying up to NGO’s, touting compliance programmes, ethics rules, and training seem to be tricks of the trade. All of this presents a challenge to regulators. Think of the safety and health investigator questioning employees about a mining disaster:

Mr. Smith, have there been safety issues in the workplace?
Oh, no; our employer has workplace signs that say “safety first.”

The tragedy of the illusion game is that at the end of the day there is a price to be paid. Remember Enron, Tyco, and Worldcom? They could do no wrong because they all had internal compliance programmes. As I watched the hockey game my mind drifted to Reggie Flemming, a one-time New Yorker Ranger forward who passed on a few years back. As a player, Flemming was known as an enforcer because of his fighting prowess. Flemming once joked that he spent so much time in the penalty box that he had his mail delivered there. Unfortunately Flemming’s final years were spent in a nursing home. After his death at age 73 doctors at Boston University studied his brain and found that he had Chronic Traumatic Encephalopathy; a brain disease associated with boxers.

Of course, the NHL has rules about fighting, so I suppose that if players fight they do so at their own peril. No doubt like other corporate masters of illusion, the NHL likes it this way.

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