What's the matter with Florida? Healthcare fraud flourishes despite enforcement efforts

Pauline Grant has a big job ahead of her as the new interim CEO of Broward Health.

The Florida system's CEO committed suicide in January, the state is looking into allegations of fraud, waste and abuse, and the governor accused two board members of interfering with that investigation and suspended them.

Last year, the system agreed to pay nearly $70 million to settle allegations that it gave doctors excessive salaries in exchange for referrals, although it did not admit any wrongdoing. Broward, a public health system with five medical centers and hospitals that had operating revenue of $971 million in 2014, is in South Florida.

Some wonder whether Grant can truly begin to turn Broward around as it searches for a permanent CEO. After all, she's a 23-year veteran of a system in a state that's known for healthcare fraud.

“The whole system in a place like Florida develops a culture of corruption and it becomes normalized,” said Patrick Burns of the not-for-profit group Taxpayers Against Fraud Education Fund. “In that world, it's so easy to rationalize lying, stealing and cheating. There simply aren't enough enforcement resources.”

Since January, HHS has touted about a dozen enforcement actions over alleged Medicare and/or Medicaid fraud in Florida, and the U.S. Justice Department has announced more than 15. In the Southern District of Florida alone, close to 900 people have been charged with fraudulently billing more than $2.5 billion to Medicare since 2007, according to the Justice Department.

Experts say the state's high number of Medicare beneficiaries and its proximity to countries where fraud may be more common make it fertile ground for fraudsters looking to rip off the government and run. In addition, larger Florida systems such as Broward may succumb to the same pressures faced by systems across the country. They're navigating complex laws surrounding physician contracting, facing stiff competition for doctors and battling whistle-blowers eager to reap rich rewards.

Florida's recent hospital settlements include Adventist Health System in Alamonte Springs, which paid out $118.7 million, and Halifax Health in Daytona Beach, which paid $85 million. Both were accused of illegally compensating physicians. Halifax denied wrongdoing. Adventist said it regretted its lapses in oversight and made changes, but the settlement included no admission of liability.

“South Florida is ground zero for Medicare fraud,” said Dr. Michael Reilly, the whistle-blower in the recently settled fraud case against Broward.

While Florida's overall patient costs are lower than the national average, the size of its aging population and a fee-for-service system that's stuck in overdrive draw potential fraudsters.

Miami-Dade County had per capita standardized Medicare costs of $14,470 in 2014—a figure 36% higher than costs statewide and 61% higher than national per capita costs, according to the CMS. At least part of that high cost may be because of fraud, said Steve Ullmann, chairman of the Department of Health Sector Management and Policy at the University of Miami School of Business Administration.

Florida, with its large senior population, had 27 clinicians among 100 providers that collected the most Medicare Part B payments in the nation, according to CMS data posted last week. Some of those clinicians' payments may reflect services rendered by multiple individuals.

Fraud is not an easy problem to solve. In 2007, federal, state and local investigators kicked off the Medicare Fraud Strike Force team in Miami. Tampa Bay and seven other areas across the country now also have such teams.

Fort Lauderdale, Miami and four other areas nationwide have CMS-imposed moratoriums on new Medicare home healthcare agencies—a move also meant to curb fraud in those settings.

Yet, “It's as bad now as it's ever been,” said Kirk Ogrosky, who founded the Miami strike force program when he was deputy chief of the Justice Department's Fraud Section in the Criminal Division. “It's an exhausting job and you never really make a dent.”

Shimon Richmond, special agent in charge of the Miami region of HHS' Office of Inspector General, argues that enforcement efforts are working, citing a crackdown on fraud affecting community mental-health centers several years ago. Billings in that area of South Florida plummeted, he said.

Still, Richmond acknowledged there aren't clear numbers to measure whether less healthcare fraud is occurring in Florida overall. And, he added, fraudsters are getting better at hiding. They're going to great lengths to make their sham businesses look more legitimate, such as by paying other individuals to secure the necessary business licenses and bank accounts.

“For every case I indicted, I'd learn about 100 more,” Ogrosky said. “You could never get ahead of it.”

Richmond said many individuals charged with healthcare fraud in Florida flee overseas, and a significant amount of fraud proceeds are scuttled away off shore.

The culture of corruption goes up the chain, Burns charged. He noted that Gov. Rick Scott was CEO at HCA amid a federal fraud investigation that resulted in the hospital giant paying a $1.7 billion settlement. Scott, who was never charged in relation to the allegations, did not respond to requests for comment.

Lately, Scott has been busy dealing with Broward. He recently appointed the former chair of the Florida ethics commission to the public health system's board. That followed his suspension earlier this year of two board members.

One, David Di Pietro, was reinstated to his post by a judge. Di Pietro said in a subsequent letter to Scott that he had tried to fight corruption within Broward, but Broward Health “is stifled with so much political interference, that my continued membership is utterly futile.” Di Pietro has since resigned.

Broward's new interim CEO, Grant, denies that there's a culture of corruption at Broward and says the system has taken steps to fix any issues with physician contracts following its federal settlement last year.

Grant said she can't explain the political struggles at the top of the system, and she's accepted that she can't control them. She wants to focus on quality healthcare and making employees feel proud to work for Broward.

Ogrosky, who left the Justice Department and is now a partner at law firm Arnold & Porter, said anti-fraud efforts should be directed toward front-end payment of claims. “You can't prosecute your way out of fraud,” he said.