Texas Tribune: Worker's Comp Whistleblowers

[Winehole23]

On a brisk day in mid-February, state fraud enforcement attorney Cathy Lockhart got a terse memo from the human resources department atthe Texas Department of Insurance and an escort out the door. She had been put on "emergency leave." A few weeks later, the department officially terminated her, citing “secret and clandestine” activity — namely, that she researched how much money had been spent on medical fraud investigations that her supervisor had abruptly ed.


Shortly before getting fired from the department’s Division of Workers’ Compensation — and ordered to cease all contact with her colleagues — Lockhart had been putting the final touches on enforcement actions against eight doctors accused of fraudulently overbilling and overtreating patients. The cases represented “the first big batch [of doctors] to go to enforcement” in several years, she says. But Commissioner Rod Bordelon, who oversees the workers' comp division, ordered the cases thrown out, she says. “I’m told in January, 'Drop 'em,'” Lockhart says.




Lockhart, along with three other former division employees who have come forward, say thedivision's staff identified and recommended sanctions for nearly 70 Texas physicians who overbilled and overtreated patients, engaging in such practices as ordering needless surgeries or prescribing unnecessary narcotics. In the process, the former employees say, a relatively small number of rogue doctors cost insurers millions of dollarsand, more importantly, placed patients in harm's way. Yet since 2005, division records show, the state has sanctioned just five doctors with removal from the workers’ comp system —and only in cases involving paperwork violations rather than harm to patients. The other cases are said to be pending.

http://www.texastribune.org/stories/...investigation/

[Winehole23]

Among the highest-profile of those investigations was one that targeted the top-paid workers’ compensation doctor in 2002, Houston orthopedic surgeon Eric Scheffey, who was barred from the system in 2003 and later lost his medical license, the Chronicle reported. Administrative law judges found that Scheffey had performed 29 surgeries on 11 patients that were either partly or entirely unnecessary. Two of the patients died after unnecessary back surgeries. Enforcement action was also taken against Houston spine surgeon Mark McDonnell in 2005, also for performing unneeded surgeries and providing substandard care. He was the state’s third-highest-paid workers’ compensation care provider in 2002, collecting $3 million in claims, the Chronicle reported.


Ford and Nemeth recall those years as the time when they were effective — they were actually routing out unscrupulous doctors. But since late 2005, Ford says, he hasn't overseen any removals of bad doctors who were overbilling the system or providing patients unnecessary care, despite review panels finding violations and recommending action.





Asked by the Tribune to respond to that charge, the division provided records of five removals since 2005. Ford says they all involved administrative violations rather than systemic overbilling and patient abuse. "This is like arresting a kid for stealing a Snickers bar but letting the child molester go free," Ford says.

[boutons_deux]

Doctors making 100 of $K/year are part of the oligarchy, well connected, an old boys network, a self-pertuating club, that knows how to take care of and protect its own.

"I read" where the estimates for Medicare fraud run up to $200B/year.
Even organized crime is involved.

[Nbadan]

It's also about protecting against medical malpractice suits in TX... so they eventually get the medicare abusers off the dole with no fan-fair...the victims families get squat...

[Nbadan]

Most families pay between $500 - $1000 per month on private insurance that may or may not pay when they eventually need it, and they have high-deductibles and co-pays..that's outrages....the bulk of people are paying for high-tech care that they would never be able to afford to pay for should they need it without affordable caps on costs....lets let individuals cover those costs in a catastrophic care plan on their own while the minor stuff, including some out-patient stuff, is regulated by the govt using posted costs like everything else so people can shop around...

[RandomGuy]

Interesting. The state auditors did finishe their review of the Dept. of Worker's Comp.

96 pages.

http://www.sunset.state.tx.us/82ndre...wcd/wcd_sr.pdf

Th e Division’s Complicated Dispute Resolution Process Often Fails to
Provide a Quicker, More Accessible Alternative to the Courts ............................... 13

#2 Th e Division’s Medical Quality Review Process Needs Improvement to
Ensure Th orough and Fair Oversight of Workers’ Compensation
Medical Care .................................................. .................................................. ...... 25

#3 Th e Division Cannot Always Take Timely and Effi cient Enforcement
Actions to Protect Workers’ Compensation System Participants ............................ 33

#4 Th e Division’s Oversight of Designated Doctors Does Not Eff ectively
Ensure Meaningful Use of Expert Medical Opinions in Dispute Resolution......... 39

#5 Th e Division’s Responsibility for Making Some Individual Claims
Decisions Confl icts with Its Oversight and Dispute Resolution Duties ................. 45

#6 Employers Outside the Workers’ Compensation System Are Failing to
Report Information the Legislature Needs to Evaluate the Health
of the System .................................................. .................................................. ...... 51

#7 Texas Has a Continuing Need for the Division of Workers’ Compensation ........... 55

[RandomGuy]

Doctors making 100 of $K/year are part of the oligarchy, well connected, an old boys network, a self-pertuating club, that knows how to take care of and protect its own.

"I read" where the estimates for Medicare fraud run up to $200B/year.
Even organized crime is involved.

Indeed. Medicare fraud, like any insurance fraud, is big business.

[EVAY]

I have personally refused to go along with two unneccessary 'tests' that two different docs wanted me to get done in the last year alone. I am not trying to die...I am a lucky person who has phenomenal insurance coverage, and once docs see that, they want to test me out the wazoo, because it is all going to get paid for by my insurance.

It infuriates me to see docs engage in this kind of fraudulent practices, but I suspect that most folks my age ( social security eligible and great insurance) never question whatever a doc orders.

Let's face it...docs 'game' the system just like lots of other folks.
Aren't 'whistle blowers' supposed to be protected?

[TeyshaBlue]

I have personally refused to go along with two unneccessary 'tests' that two different docs wanted me to get done in the last year alone. I am not trying to die...I am a lucky person who has phenomenal insurance coverage, and once docs see that, they want to test me out the wazoo, because it is all going to get paid for by my insurance.

It infuriates me to see docs engage in this kind of fraudulent practices, but I suspect that most folks my age ( social security eligible and great insurance) never question whatever a doc orders.

Let's face it...docs 'game' the system just like lots of other folks.
Aren't 'whistle blowers' supposed to be protected?

I look at little side-ways at the recent upswing in Doctor owned testing facilities. You've got groups of doctors investing in MRI centers...what do you expect? Lots of MRI's, that's for damned sure. The surgical centers kinda ping my radar the same way, although I recently had eye surgery at a doctor owned surgical center. I didn't have a choice as to where the surgery was to take place...my opthamologist had ownership in the center so that's where I had to go. I have no idea how cost effective that solution was since I have no idea what the total charges were. My co-pay was pretty hefty tho.


Fraud? Arguable. Gaming? Almost certainly.