by AT News Team

Last week United States District Judge John Antoon II ruled for the second time that a “whistleblower” fraud recovery lawsuit brought by a former employee and a physician at Florida Hospital in Orlando has sufficient merit that it must move ahead. Lawyers representing the nonprofit health care organization which is affiliated with the Seventh-day Adventist Church had argued that the two did not have adequate knowledge of the situation nor written evidence to back up their allegations and asked the judge to dismiss the case.

The first request to dismiss the case was refused by the judge in July last year. He ruled at the time that the allegations and supporting evidence met the requirements of the False Claims Act, a Federal law dating back to the Lincoln administration which has been used to recover $22 billion between 1987 and 2008, according to the Department of Justice.

This case was initiated in 2010 by Amanda Dittman, a compliance officer involved with third-party payments from 1996 to 2008, and Dr. Charlotte Elenberger, a physician who had privileges at Florida Hospital from 1995 to 2009. They charged that Adventist Health System engaged in fraud because it “routinely misused billing code modifiers to unbundle payments for bundled medical services, charging the government more than the bundled price,” reports Law 360, a legal news service.

A specific allegation in the legal complaint filed at the time was that AHS “misused a price file number for a 5,000 microgram does of the drug octreotide when only a 1,000 mcg dose was administered, overcharging the government by nearly $2,500 per dose.” The two women worked with a radiology practice that discovered that “AHS also routinely billed the Federal government for computer-aided detection software analysis of mammograms, even when no such analysis was done.” When the radiology practice “learned that it had received improper reimbursement [for services] supposedly preformed on behalf of AHS, it promptly refunded insurers and the government,” Law 360 summarized from the original complaint.

AHS refused to reimburse the government, the two whistleblowers allege. They believe that someone among AHS personnel was afraid that the refund would trigger a government audit.

This is not the only case that has been brought against AHS under the False Claims Act, nor the only whistleblowers who allege wrong-doing by the health care organization. In a different case last year, AHS agreed to pay $3.9 million to the Federal government along with 13 other health care organizations that participated in a total $12 million settlement.

One thing that makes cases of this kind controversial is that False Claims Act rewards “whistleblowers” with 15 to 25 percent of any money that is paid back to the government. “In a sense,” one attorney told Adventist Today, “these whistleblowers are like bounty hunters. There is potentially money to be made from this kind of lawsuit.” That is one reason why there are arguments before the judge as to whether or not the persons filing the complaint actually have sufficient first-hand knowledge to have really seen fraud perpetrated.

“I don’t know anything about these two people or this case,” another source told Adventist Today, “but sometimes these claims are from disgruntled former employees trying to get even.” Another possibility is much more complicated. The Federal government is engaged in a wide effort to reduce the cost of health care and one of the methods for doing this is to reduce waste and fraud. A source with knowledge of current trends in health care told Adventist Today that some in the government are encouraging lawsuits of this kind simply to pursue overall savings in health care costs.

“These are often settled without a determination of fact. The health care organizations involved simply decide that it is cheaper to pay a negotiated amount than to defend themselves. It is almost impossible to know what is really going on here.”

Health care is a life-and-death matter for every person and science has made wonderful advances possible in the healing arts. It is also a central piece in the mission of the Adventist Church. And it has never been more complicated and challenging.