I decided it might make sense to hone my argument about why I believe the inadequate mental health services provided by Kaiser constitute Medicare fraud, and to email and snailmail my honed argument to Belinda Cross at Health Integrity. So here’s what I wrote and sent today. I incorporated what I learned from my conversation with Belinda on 11/13/14 regarding an annual process reconciling delivery of services with monies reimbursed. Even though there are big holes in my understanding of how the whole process works, it seems that those with a clearer understanding of the system will be able to fill in the blanks.
I am a former staff therapist who worked at Kaiser Santa Rosa’s Medical Center in the Psychiatry Department, starting in September 2006 and ending almost eight years later when I was escorted from my office in retaliation for whistle-blowing in May 2014. As a steward for the union of Kaiser’s psychotherapists, the National Union of Healthcare Workers, I was privy to information about policies, procedures, and their effects at Kaiser medical centers beyond Santa Rosa — throughout Northern and Southern California. And I believe the same policies that operate in California are in place at Kaiser medical centers throughout the United States which leads me to believe that the fraud I am reporting here is operating on an enormous scale.
My belief that The Kaiser Medical Group (TPMG) has defrauded the Medicare Advantage program is based on a partial understanding of how Medicare reimburses Kaiser. I will describe my experience with clinic policies and leave it up to you to assess if you believe, as I suspect, that there is a strong case for fraud. My understanding is that if there seems to be a strong case, then you forward your information on to the Office of Inspector General for further investigation.
Starting several years ago, therapists and psychiatrists in the Psychiatry Department in Santa Rosa were instructed to fill out a form known as “Medicare refresh” whenever the form appeared in our mail boxes. The form listed one or more diagnoses. Therapists had been instructed to check a box next to each diagnosis, verifying that the patient would be continuing to receive treatment for the diagnosis listed. Sometimes the forms contained “physical” diagnoses, like Hypertension. Therapists in Santa Rosa were instructed to comment on mental health diagnoses only. The most common diagnoses that we “refreshed” were Major Depression and Panic Disorder. About a year before I left work for Kaiser, a more thorough training was given regarding the Medicare refresh process. In addition to filling out the paper forms, we were instructed to chart in each patient’s electronic medical record a plan to treat the conditions being refreshed.
My understanding is that these forms are part of a system that Kaiser uses to get reimbursed by Medicare Advantage for medical conditions that raise patients’ “risk scores.” I further understand that there is a “reconciliation” process by which Medicare auditors review a sampling of cases in order to ensure that patients with higher risk scores are receiving diagnosis-specific treatments for the conditions that raised their risk scores. The reconciliation process implies that Medicare auditors compare treatment provided (services rendered) against a standard of care for each diagnosis.
If there is any standard of care expected for treating mental health conditions, I believe it is not being met by the behavioral health system in place at Kaiser in California. It appears fraudulent, therefore, that Kaiser accepts these payments for services never or only partially rendered.
Throughout my tenure at Kaiser, treatment of mental illness has been inadequate in at least two significant ways: (1) markedly poor access to primary individual therapists and (2) an over-reliance on group programs. These inadequacies contradict the assumption (in the Medicare refresh process) that effective treatment plans for mental health patients are in place.
Markedly Poor Access to Primary Individual Therapists
Throughout my years at Kaiser in Santa Rosa, the waits between appointments with a primary individual therapist were, on average, 4 weeks, regardless of the seriousness of the patients’ symptoms. In the last year I was there, these waits got even worse in Santa Rosa, averaging 6 weeks. I was able, through my activities as a union steward, to confirm an average of 4-8 weeks between appointments with primary individual therapists across California and across conditions being treated. Due to the intervention of the California Department of Managed Health Care (DMHC), the amount of time a new patient currently waits for an initial appointment has in some medical centers improved. But according to my colleagues still at Kaiser, waits between follow-up appointments after that initial screen continue at their historical, unacceptable level.
Over-reliance on Group Programs
Kaiser has attempted to defend their short supply of individual therapy appointments by stating that their group programs provide better care than individual appointments. And this might be true, if it weren’t for the fact that most people do not attend the groups. Over the almost eight years I worked at Kaiser, the drop out rate for the groups addressing the two most often reimbursed categories of mental illness, Panic Disorder and Major Depression, had a drop out rate of 75%. That means that three out of four patients drop out of treatment between the initial referral to the group and the group’s final session. Without proper support from an individual therapist, the vast majority of patients do not complete the treatment plan that Medicare is reimbursing.
In summary, Kaiser is being reimbursed by Medicare to provide the additional resources necessary for treatment of certain mental health conditions. Therapists and psychiatrists are by rote signing off on the paperwork supporting this system. Therapists are unified in asserting that the supply of individual therapy hours is woefully inadequate to provide meaningful treatment and that group programs are only effective for the small percentage of patients that complete the programs. Under pressure from the DMHC, Kaiser is starting to increase its supply of individual therapy hours. It will be quite some time, however, before supply meets the ever-increasing demand.
Medicare Advantage should be refunded all the monies paid over the years to Kaiser for treatments promised through the risk score process but not provided. Future reimbursements for mental health conditions should be withheld until the supply of therapists is adequate to treat those conditions being reimbursed.
(38 days to go.)