One-quarter of the Medicare fraud cases prosecuted in the country last year were in the Miami district, and one dedicated nurse is a driving force behind this fierce defense of our federal healthcare insurance program for retirees.
Peggy Sposato, ARNP, MHM, spends her days scanning reports and databases in a quest to crack down on perpetrators of Medicare fraud.
“It’s a daily challenge, which I love,” Sposato says. “If I can put money back into Medicare, I have done a service for everybody.”
Sposato typically begins her day talking with agents who might ask her whether she has heard of a certain provider or how a piece of equipment might be used. She reviews reports from safeguard contractors, private firms watching for fraud or abuse of the system, and can delve deep into the data to look for trends and clues. These can be found in types of codes billed, complaints by beneficiaries, claims volume and frequency, and the logic of the claim, such as why a provider would order an orthotic for a patient who received a prosthetic for that limb one month earlier.
“Sometimes you just know that there is no way it could be realistic,” Sposato says.
Company ownership and history also can point toward a problem. For instance, Sposato might pick up on a newly organized company billing a half million dollars or more. Or the Medicare forms may show a different owner than state records, which is a red flag.
Once Sposato spots a suspicious trend, she alerts the federal investigative agents. She works at the only healthcare fraud fusion center of its kind in the country, collaborating with prosecutors, agents from the FBI, the Office of Inspector General of the Health & Human Services department, and other law enforcement agents. They share access to documents, and the team often interviews people at the center.
“The goal of that facility was to bring everyone together, so as to create synergy and greater effectiveness in our battle against Medicare fraud,” says Eric I. Bustillo, chief of the Economic & Environmental Crimes Section of the U.S. Attorney’s Office Southern District of Florida in Miami.
Sposato educates the investigators and attorneys about medical terminology and the equipment and explains how they relate to the diagnosis. She suggests questions for the investigators to ask physicians or explains what to look for in the medical record. She may recommend an agent look at the neck of a patient receiving tracheostomy care supplies or check for a scar on a patient who had decubitus wound care supplies delivered.
“I look for the logical,” Sposato says. “I give them different pieces of information so they can interview the beneficiaries and come back with valid information they need to develop their cases.”
The process has been effective. Last year, the office prosecuted 120 cases, alleging more than $638 million in healthcare fraud. Bustillo expects to exceed that in 2008. Nationwide, U.S. Attorney’s offices filed 434 cases in 2007.
“We’re always investigating; there is no downtime,” Sposato says. “There is a constant turnover. You just finish one case, and you are getting ready to charge three or four more. There are dozens of ongoing investigations at one time.”
The days are much different from the nursing Sposato practiced after graduating from a diploma program in Upstate New York and coming to Florida in 1961. She worked in a hospital, home care, and skilled nursing before becoming a nurse practitioner in 1974 and operating a clinic. About 12 years ago, ready for a change, she completed a few chart audits and enjoyed it, so she decided to offer her services at the U.S. Attorney’s Office in Miami. She started working on some home health cases under a contract and was later hired as a member of the team.
“She’s a superstar,” Bustillo says. “A lot of our great success starts with Peggy. Her nursing background is invaluable.”
Bustillo says Sposato’s work has allowed the task force to more quickly process cases, seize the funds, and return them to the Medicare trust fund.
“We can charge people within weeks after they submit their last fraudulent claim,” Bustillo says. “Historically, it would take months, maybe even a year, to put the case together. Now we can do many cases in a handful of weeks. And a lot of it is due to Peggy looking at the data and quickly giving us what we need to stop this fraudulent activity.”
Sposato encourages nurses to stay alert to possible fraud and to report activity that appears illegal so it can be investigated. The Medicare Fraud hotline at the HHS Office of the Inspector General is 800-447-8477.
“The amount of fraud going on now threatens to put an end to Medicare. We need to be a bit more aware about what is going on, in terms of the healthcare community,” Sposato says. “You have to keep your antenna up to make certain you are doing the right thing. We all have a stake in this. It’s our Medicare and, hopefully, it will be there when we need it.”
Debra Anscombe Wood, RN, is a Nursing Spectrum contributing writer.