Wyoming Medical Center defrauded Medicare and Medicaid by altering hospital records to collect higher fees from the government, a whistleblower alleges in a federal lawsuit unsealed this week.
The document, filed by a hospital worker in 2007, accuses records clerks of changing the admission statuses of patients without a doctor’s order. The change allowed the hospital to seek higher reimbursements from federal insurance programs.
The whistleblower, a worker named Gale Bryden, suspected the practice continued even after she notified top hospital administrators in the fall of 2006. Bryden claims she shared her concerns with Vickie Diamond, who was chief operating officer at the time and is now the hospital’s president.
Hospital attorney Dick Williams denied there was any attempt by the hospital to defraud the government or private insurers. If mistakes did occur, they were inadvertent or accidental, he said.
Diamond said she has no memory of meeting with Bryden to discuss concerns about fraudulent billing.
“There is no recollection from my part or from anybody else,” she said.
Bryden, who was responsible for collecting fees that had been denied by insurers, filed the lawsuit on behalf of the federal government in October 2007. The suit seeks a percentage of any award or settlement in the case.
Because she made the allegations under a federal whistleblower law, the suit was put under seal as the government investigated the matter. U.S. District Judge Scott Skavdahl ordered the documents unsealed Monday.
Federal attorneys notified the court last week that the government wouldn’t be intervening in the case for now because its investigation isn’t complete.
Other court documents related to the case — including two amended complaints filed by Bryden’s attorney in 2008 and 2009 — remain under seal. In the unsealed documents, there is no mention about whether the alleged wrongdoing continued after Bryden filed her original complaint.
Bryden no longer works for the hospital. Diamond said she doesn’t know the circumstances that led to the whistleblower’s departure.
Bryden’s attorney, Jeffrey Gosman, did not return a message left Tuesday seeking comment.
The investigation into the fraud allegations involves both the U.S. Attorney’s Office and the Department of Health and Human Services. John Powell, spokesman for the U.S. Attorney’s Office in Wyoming, said he couldn’t discuss the case — including the amount of money involved — because the matter remains under investigation.
Bryden became aware of the suspected fraud while serving on a hospital committee that discussed the admission status of patients, according to the lawsuit. She observed workers submitting claims to insurers that differed from the services the hospital actually provided, the lawsuit says.
“WMC, by and under the direction of the highest levels of hospital management, was submitting claim forms that were inconsistent with the medical records for the purpose of obtaining higher levels of reimbursements from both the private and government program insurers,” the lawsuit states.
Some claims were changed to show a smaller reimbursement, the suit says. But most, according to the suit, were altered to provide a higher reimbursement rate.
The changes concerned the admission status of patients at Wyoming Medical Center. The suit alleges clerks altered patient statues from “outpatient” to “inpatient” without a doctor’s order.
The lawsuit cites 21 examples of clerks modifying patient records. The changes allegedly resulted in increased charges ranging from $35 to $1,100, the lawsuit says.
Billing clerks aren’t permitted to alter the admissions status of patients, and generally, medical records are finalized when a patient is discharged. The suit, however, claims workers retroactively made changes to patient records.
Under Medicaid regulations, the outpatient status is given to patients with hospital stays of less than 24 hours. The term “inpatient” refers to someone who was admitted for more than that time.
Bryden first went to her supervisor with her concerns sometime in 2006, according to the lawsuit. Several weeks later, after failing to hear back, she met with Diamond and another person, the lawsuit says.
During that meeting, Diamond instructed Bryden to meet with managers of the departments that were involved and tell them to stop what they were doing, the suit states. Two weeks later, Bryden explained her concerns at a meeting of several administrators, the suit says.
On Nov. 29 of that year, the director of medical records informed Bryden via email that he’d spoken with Diamond, and “They were going to leave matters as they were, with the idea that they would try to clarify the patient status in a more timely fashion in the future,” according to the lawsuit.
Sometime later, the hospital disbanded the committee that Bryden served on. She alleges the practice of falsifying patient statuses continued.
Diamond said she met with Bryden a few times, but never to discuss concerns over records being fraudulently altered. She said no one else at the hospital recalls such a meeting either.
Wyoming Medical Center has cooperated with the government’s investigation since officials were notified of it in May 2009, said Williams, the hospital attorney. The hospital has provided the Department of Justice with a “massive amount of information” on claims from 2002 through 2009.
“We have denied from day one that there was any intent to improperly bill the government ... or that there was a systematic direction from anyone to alter statuses or records,” he said.
Medicare and Medicaid regulations can be difficult to understand and the hospital does its best to comply with the rules, he added.
For a three-month period in 2005 or 2006, hospital clerks with questions about a patient’s status could seek information about the doctor’s intentions. The clerk could then enter an order clarifying the status.
A Medicare intermediary informed hospital officials the procedure was OK, Williams said. The hospital stopped the practice after learning it wasn’t acceptable.
The hospital is working on a settlement for the case. Officials are hopeful one might occur within a couple of weeks.