By Christina Sponselli
posted 11-6-95
The proliferation of hospital mergers, the growth of community-based care, and other changes in the healthcare industry have attracted an assortment of opportunists bent on bilking the government of Medicare and Medicaid money. As head of the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services, June Gibbs Brown, JD, MBA, has the job of putting a lid on the double-billings, kickbacks, and other fraudulent activities plaguing Medicare and Medicaid programs.
“We find cases where people who have had no background in health care, who have run a casino, and have come into the healthcare area simply because there’s so much money to be made there right now,” she said.
The OIG was established almost 20 years ago by the Carter administration; its head is appointed by the president and confirmed by the Senate. The position is nonpartisan.
Responsible for an operating budget of about $100 million, Brown has a staff of 975, including nurses, medical records personnel, former law enforcement officers, statisticians, and computer specialists. Their job is to ferret out fraud, waste, and abuse in the 250 programs administered by the HHS. To date, the office has recouped nearly $10 for every dollar spent on investigations.
“I feel strongly that most people in the healthcare profession were attracted to that profession because they’re very honest and giving people. But it is an industry that’s just fraught with fraud right now and it’s a growing problem,” Brown told NURSEWEEK while in San Francisco last month.
This summer the Clinton administration created Operation Restore Trust, a pilot program in California, Texas, Illinois, Florida, and New York to uncover Medicare and Medicaid scams in nursing homes, home health agencies, durable medical equipment companies, and hospices.
During a routine evaluation of computer data at the Health Care Financing Administration, which administers Medicare and Medicaid programs, officials noticed a spike in Medicare payments for incontinence supplies. Statisticians found payments had risen from $88 million in 1992 to $250 million in 1994.
Further investigation revealed many suppliers were submitting claims for incontinence supplies—calling adult diapers “female external urinary collection devices.” Adult diapers are not covered by Medicare.
If, after investigating a case, the OIG finds reason to believe an illegal practice is taking place, the case is referred to the U.S. Department of Justice, which determines whether to prosecute.
The growing movement to home health care—Medicare paid almost $16 billion in home health benefits last year—and the complexity of delivery systems have increased the potential for fraudulent activities. For example, in some cases the independent environment of home health has decentralized information about the patient. “There are fewer people who have knowledge of what a certain patient needs, and this is where nurses can help a great deal,” Brown said. In some cases unauthorized charges or claims are made, but the supplies are never delivered. However, nurses are often in the position to spot the problem and advocate for the patient.
During investigations in Puerto Rico, auditors from the OIG uncovered fraud in the Medicare hospice program. Under the hospice benefit, patients with a life expectancy of less than six months may enroll in hospice programs and receive care at home or in hospital facilities. The investigation found 70 percent to 77 percent of people receiving hospice care did not qualify for it. In some cases patients’ life expectancies were misdiagnosed to meet the requirements for hospice care. Also, some cases revealed that marketing strategies offered patients incomplete or inadequate information about Medicare hospice benefits. “This is a problem for the patient because they have a one-time privilege of getting hospice care,” Brown said.
Nurses and other healthcare providers can report suspected Medicare and Medicaid fraud to the OIG by calling (800) HHS-TIPS between 6 a.m. and 5 p.m. Monday through Friday. Callers will be given a case number, and they may request their name not be used in the investigation. “We’re very, very excited about the prospect of the nurses who have day-to-day contact with the patients and who may see problems emerging getting information to us so we can investigate unusual or unreasonable activity,” Brown said.
When a person calls the hot line, the operator will ask questions about the alleged problem, such as: What is the patient’s condition? Are the supplies being ordered appropriate for this patient? Is the patient receiving the supplies that have been ordered?
With these reports from healthcare providers, the OIG may investigate and perhaps identify a larger trend for the same kind of fraudulent activity, Brown said. “We can see patterns; it might be that it’s occurring in two or three locations, but all from one supplier,” she said.
Snapshot of June Gibbs Brown
June Gibbs Brown, JD, MBA, is the first person to be an inspector general at four major agencies in the federal government, but she said her biggest accomplishments were graduating first in her college class at age 37 and raising her four children.
Married at 18, Brown separated from her husband while her children were young and became the family breadwinner in the 1950s. She worked as a school crossing guard, a real estate agent, and a mail carrier, among other jobs, before enrolling in Cleveland State University (CSU) in her mid-30s. She majored in accounting, she said, so if she had to drop out of college she could still land a job. “When I went to college there was no doubt in my mind that my children came first, and they still do. So every quarter I took every class I could, thinking that it might be the last quarter because if the children had a problem I would not continue,” she said.
In fact, Brown did graduate in 1971—at the top of her class—and passed the test to become a certified public accountant. She went on to earn her master’s degree in business administration at CSU, and began her federal career as an auditor at the Navy Finance Center in Cleveland. A few years later, she began working at the Interior Department in Denver and earned a law degree from the University of Denver.
She has been nominated as an inspector general by presidents from both parties. President Carter chose her to head the Office of Inspector General at the Interior Department. She was nominated by President Reagan to serve at NASA and later at the Department of Defense. President Clinton chose Brown for her current post.
—Christina Sponselli
Pick up the receiver and report a deceiver
To report suspected Medicare or Medicaid fraud call (800) HHS-TIPS between 6 a.m. and 5 p.m. Monday through Friday or write the U.S. Department of Health and Human Services, Office of Inspector General, P.O. Box 23489, L’Enfant Plaza Station, Washington, DC 20026-3489.