Episode 46: Whistleblowers

Two topics in the healthcare field that are rarely discussed are fraud and reporting fraud. In 2015, the guests on this episode, OT practitioners LeeAnn Holt and Kristi Emerson, were faced with a situation in their jobs that resulted in their making a report of fraud leading to a federal lawsuit being file against the company they worked for. Following that, both were terminated from their positions, which pushed them into the role of whistleblowers. On this episode of On The air, LeeAnn and Kristi share about that experience and talk about what has happened in their careers and in their lives since that time.

Occupational therapist LeeAnn Holt, OTR/L, OTD, graduated in 1989 with a BS in OT from Western Michigan University and also holds a post-professional doctorate in occupational therapy. She has worked in acute care, residential inpatient, adult and pediatric outpatient, community reentry, LTC and SNF settings, with the bulk of her career in geriatrics. LeeAnn has in some form of management or in the role of lead clinician since 1994, including four years as Regional Director of Rehab for a LTC/SNF company.
 
Kristi Emerson, COTA/L, is an occupational therapy assistant who graduated from Wallace State in 1998 with most of her OT career spent working in geriatrics. Since the time the report of fraud was made, both LeeAnn and Kristi have not worked regularly as OT practitioners. Kristi has done a little prn or "as needed" work for a contract company and has served as the administrator of a Facebook page called OT, PT, SLP therapists speak out against fraud.

Because of the actions of LeeAnn and Kristi, a legal case was brought and subsequently settled against a nursing home chain with more than two dozen facilities in the state of Tennessee settled a $230 million Medicare fraud. In the process of serving as whistleblowers, LeeAnn Kristi Emerson collected and submitted stories of patients, and that information was used as primary evidence in the lawsuit between the federal government and Louisville, Kentucky-based Signature Healthcare, which operates more than 100 facilities in 17 states.

Following is an excerpt from an article about the case posted on the Nashville Public Radio website (Farmer, 2018):

The complaint against Signature Healthcare (download here) accuses the company of systematically administering occupational, physical and speech therapy when it wasn't warranted and withholding care when government reimbursements were already maxed out. According to the suit, the unnecessary therapy pushed patients into a category where the facility was reimbursed more per day for those patients, often hitting precisely the 720-minute per week threshold for maximum payment.

As part of the $30 million settlement with the U.S. Department of Justice, the company has admitted no liability and denied the allegations. But in a statement, CEO Joe Steier says the payout "allows us to move forward in serving our residents."

Emerson says she hopes the case will still inspire other health care workers to push back when they feel pressured to do procedures they deem medically unnecessary.

We can't just blame these corporations for all of this," she says. "We have to shoulder as therapists some of the responsibility because we've allowed this to get this bad." ~Kristi Emerson, COTA/L

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Connect with Kristi and LeeAnn:

• Via email:
  • Kristi - allie1e@aol.com
  • LeeAnn - sleepyot@hotmail.com
• Via their Facebook Page - OT, PT, SLP Therapist Speak Out Against Fraud

As therapists, whether we are actively practicing or in a nonclinical role such as a manager or director, we literally make hundreds and sometimes thousands of decisions a day.  We are presented with patient treatments and have to adjust what we are doing moment by moment based on the patient's response.  Which task will prepare for my patient's session today?  Which goal will I focus on today? If my patient moves in this manner, how do I adjust my treatment task?  If my patient responds in that manner, how do I adjust my task?
 
When performing an evaluation, we have to decide what goals are best, what modalities are appropriate, what treatment situations are best.  We have to decide what frequency and duration is appropriate for the individual we are evaluating.  What goals are important to our patient, what is their priority? What co--morbidities influence the main diagnosis we will focus on?
  
As managers and directors, we have to decide how to assign patients and therapist schedules.  We have to decide what kind of staffing budgets allow.  Is the staff performing efficiently and doing their jobs appropriately? How do I provide the best functional working environment for staff to allow their patients the best care?  Can we order equipment and what equipment do we order?  How do we coordinate attending a meeting? And how am I going to do all this paperwork?

There are 3 key questions you should ask yourself with each and every decision you make.

1.  Is it best for the patient?
2.  Is it ethical?
3.  Is it legal?

If you can answer yes to these questions, then you should be ok. I recommend keeping a copy of your state's practice act with you at all times.  Treatments and billing that you are asked to do should not challenge your state's practice act.

Keep a copy of AOTAs code of ethics with you at all times.  Treatments and billing that you are asked to do should not challenge AOTA's code of ethics.

Know the different insurance rules.  You may assume supervisors or managers will understand the various insurance requirements and trust that they will only ask you to do treatments and billing that are within insurance guidelines.  This is not always the case.  You need to educate yourself on what is legally billable, whether it is for Medicare/Medicaid, Worker's Compensation or other private insurances.  

​You are responsible for the integrity of our profession." ~LeeAnn Holt, OTR/L, OTD

Resources:

• AOTA webpage: Reporting Fraud, Abuse and Other Noncompliance Incidence 
• OT Practice article written by Kristi and LeeAnn: An OT/OTA Team's Experience Reporting Illegal Skilled Nursing Facility Billing: Relying on Core Values, AOTA, and the OIG to Persevere

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Kristi Emerson

LeeAnn Holt