Whistleblower suit: Hospitals defrauded Medicaid

Kate Brumback | AP Business Writer

ATLANTA (AP) — Two large hospital operators paid kickbacks to clinics that directed expectant mothers living in the U.S. illegally to their hospitals and filed fraudulent Medicaid claims on those patients, a federal whistleblower lawsuit unsealed late Wednesday said.

Naples, Fla.-based Health Management Associates and Dallas-based Tenet Healthcare and their affiliates entered into contracts with clinics operated by Hispanic Medical Management and Clinica de la Mama and their affiliates, the lawsuit says.

The clinics then referred pregnant women living in the country without authorization to for-profit hospitals operated by HMA and Tenet in exchange for kickbacks from fraudulent Medicaid claims, the lawsuit says.

The Medicare and Medicaid Patient Protection Act, known as the anti-kickback statute, prohibits paying for or accepting money to arrange for medical treatment under federally funded programs.

An HMA representative said in an email that the company does not comment on pending litigation.

Tenet issued a statement on behalf of its hospitals named in the suit, saying it believes the agreements "were appropriate and provided substantial benefit to women in underserved Hispanic communities served by those hospitals. The services provided under these agreements included translation, determination of Medicaid eligibility, and other services designed to improve the delivery of obstetric care and increase the likelihood of a safe birth and a healthy baby."

Phone numbers for Hispanic Medical Management and Clinica de la Mama, both in Georgia, could not immediately be found.

The federal whistleblower lawsuit, filed by Ralph Williams, a former chief financial officer for HMA, says the kickback scheme went on for more than a decade. The state of Georgia has also joined the lawsuit to recover state Medicaid funds.

"These hospitals paid Clinica kickbacks camouflaged as interpreter service payments to funnel emergency Medicaid patients their way and increase their bottom line," Georgia Attorney General Sam Olens said in a statement. "As attorney general, I take seriously my responsibility to protect the integrity of Georgia Medicaid and to ensure that those who defraud the program are held accountable."

Clinica recruits pregnant women who are in the country illegally to its prenatal clinics using the slogan, "we care about your health, not your immigration status," the lawsuit says. The clinics then directed these vulnerable patients to the HMA and Tenet hospitals, which pay for the referrals, the lawsuit says.

Those in the country illegally are not eligible for Medicaid coverage although hospitals can be reimbursed for treatment of emergency services provided to those in the country illegally and Medicaid rules consider childbirth an emergency medical condition.

The lawsuit says Williams began working at HMA in April 2009 and one of his duties was to monitor contracts and approve the payment of bills. Shortly after he arrived, he discovered a contract between an HMA hospital in Monroe, Ga., and Clinica for Spanish interpreter services, the lawsuit says. He investigated and found no evidence of interpreter services, but eventually found that Clinica was being paid for referring pregnant women in the country illegally "for government subsidized deliveries," the lawsuit says.

Soon after he voiced his concerns about the fraudulent arrangement to company leaders, Williams was fired without reason, the lawsuit alleges.

The lawsuit says Williams' direct supervisor had previously worked for Tenet in South Carolina. The lawsuit alleges that Tenet used a similar scheme in a number of its hospitals, including Atlanta Medical Center, four others in Georgia and Hilton Head Hospital in Hilton Head, S.C.