Gloria Pryor, Michael Payne and Melissa Church, former employees of an Adventist hospital in North Carolina, joined together to file a qui tam lawsuit alleging that Adventist Health System paid doctors outrageous sums and generous benefits for referrals to Adventist-owned hospitals in several states.
Adventist paid $118.7 million in 2015 to settle the whistleblower lawsuit. Below are excerpts from a story published in Health System Specialist, elaborating on the lawsuit and the experiences of the three whistleblowers, who were represented by Phillips & Cohen.
Healthcare Whistleblowers Risk Careers to Keep Patients Safe
Gloria Pryor and Michael Payne had both entered healthcare on the clinical side: she as a nurse and he as a respiratory therapist. They had spent years practicing before they wound up on the administrative side, working as risk managers for Park Ridge Health, which includes a hospital and a variety of physician practices in and around Hendersonville, N.C. and is affiliated with the Florida-based Adventist Health system.
In the mid-1990s, Adventist began to aggressively purchase medical practices in western North Carolina. In the years that followed, Pryor, Payne and a colleague Melissa Church, Park Ridge’s executive director of physician services, had come across odd coding patterns regarding the work of local doctors.
Park Ridge lavishly used what’s known as a Q6 modifier to regular billing codes. It’s applied when one physician uses another physician’s Medicare number for billing. That typically occurs when the former is on vacation and contracts with the latter to care for their patients while absent. But the Q6 modifier was being used so often that it raised questions about whether the physician borrowing the other doctor’s Medicare number had been properly credentialed, according to Pryor.
But that was only part of the issue. According to court records on the matter, a local surgeon had their lease payments for a BMW and a Ford Mustang covered by Park Ridge. A surgeon who specialized in pediatric urology was being paid $30,000 a month for just three days of work. A similar salary was paid to a family practitioner – double the going rate for the area. And no action was often taken against doctors even when their practices were not meeting revenue targets, therefore making them contractually subject to salary cuts and financial liabilities. In return, it appeared the doctors quietly and consistently referred their patients to Adventist-owned facilities, a violation of federal kickback statutes.
“I feel like we repeatedly appropriately documented and reported endlessly to the appropriate people” in the chain of command, says Pryor, who shared an office with Payne. They then consulted Church (who was not available for an interview). She agreed something was amiss. The trio decided to become relators together, hiring [Peter] Chatfield’s firm and filing suit in 2012.
Read the entire story in Health System Specialist: Part 1: “Healthcare Whistleblowers: Inside Their Hearts and Minds.” Part 2: “Healthcare Whistleblowers Risk Careers to Keep Patients Safe.”