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Originally published February 28, 2012 at 4:03 PM | Page modified February 28, 2012 at 7:01 PM

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Support state bill to fight Medicare/Medicaid fraud

Guest columnist Jim Alderson, who uncovered a hospital chain's Medicaid/Medicare fraud scheme, urges Washington to pass Senate Bill 5978 to protect whistle-blowers, taxpayers and Medicaid/Medicare patients.

Special to The Times

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WASHINGTON has the opportunity to recover millions of taxpayer dollars lost to Medicaid fraud. It starts with passing legislation that 28 states already have. The U.S. Department of Justice calls this the best fraud fighting tool we have.

"Billion" isn't a word we use very often in Whitefish, Mont., but in 1993 when I became a whistle-blower, I started down a path that uncovered a fraud scheme worth $1.7 billion to taxpayers.

You may recall my case: the largest hospital chain in the country, Columbia/HCA (Hospital Corporation of America), was intentionally providing fraudulent reports to the government for Medicaid/Medicare reimbursements, avoiding detection by keeping two sets of books and marking evidentiary files "Confidential."

A lawsuit eventually filed by the Justice Department said Columbia/HCA "systematically defrauded the United States for at least 10 years ... by including in their individual provider and home office reports reimbursement claims that they knew were greatly exaggerated and/or that were not properly reimbursable at all."

It began because I refused to go along with the fraud when Columbia/HCA came in to manage the 44-bed hospital I worked at.

I could have looked the other way, but that's not who I am. I knew I'd be blackballed in the health-care industry — and I was. I knew I could lose my job — and I did. But I also knew in my heart it was the right thing to do. So I brought it to the government's attention and began a lawsuit.

The company spent $337 million trying to defend itself against this case. This meant my attorneys had to spend millions to keep it going. The government wanted to participate, but didn't have the resources to give all its attention to this case. So my case was what's called a qui tam case, brought under a law which allows people with intimate knowledge of fraud against the government to bring a case on the government's behalf.

Now, state legislators in Olympia are on the verge of passing such a law, joining the federal government and other states, so that people like me can do the right thing.

It enables Washington to participate in multistate qui tam cases, which it could not do without the law. Also, the federal government will give Washington a larger share in joint cases, to encourage more crackdowns.

The Department of Justice estimates that 5 to 10 percent of Medicare/Medicaid payments are fraudulent — that's up to $680 million in Washington in a year — and that 80 percent of the money it recovers are from cases started by whistle-blowers like me.

Senate Bill 5978 is expected to bring back at least $10 million a year once the state starts participating in these cases. The law also acts as a fraud deterrent.

Some people don't like that this measure allows whistle-blowers to receive a small portion of the recovery. But these cases are impossible to bring without someone like me reporting the fraud — that comes at great cost.

After getting fired, I had to leave town to find another job 300 miles away. I lived in a $150-a-month apartment while selling my home and relocating my family. I sacrificed my family's welfare for 13 years as this saga dragged on in court and my name was dragged in the dirt.

Sometimes you have to make great sacrifices to help others and I believe those good deeds should be rewarded. Receiving some of the retrieved money gives people incentive to do the right thing and expose fraud.

Washington must pass SB 5978. It protects whistle-blowers, taxpayers and Medicaid/Medicare patients. It's a true win-win we can all support.

Jim Alderson is a retired certified public accountant living in Whitefish, Mont.

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