GRAND RAPIDS, Mich. (CN) – An insurance analyst claims Priority Health Managed Benefits fired her for blowing the whistle on its instructions that her “‘only focus’ should be to look for and ‘add’ codes which would gain additional payments … from Centers for Medicaid and Medicare Services,” and to ignore “deletes,” or false or incorrect codes that bring the company overpayments.
Jill Poffinbarger claims Priority Health fired her for refusing to “turn a blind eye” to its systematic efforts to “collect more money from the government” through overpayments from Medicare and Medicaid.
Poffinbarger claims the Michigan-based company told her and four other Medicare risk adjustment analysts “that their ‘only focus’ should be to look for and ‘add’ codes which would gain additional payments for defendants from CMS [the Center for Medicare Services].”
Poffinbarger claims the company’s director of revenue management & premium billing, Matt Smith, ordered her through her direct supervisor, a senior manager in its medical operations administration, to “commit fraud” and “break the law.”
Poffinbarger claims that the company, “through Smith, insisted that plaintiff completely ignore the other side of her duties and the law, which was to also accurately deport ‘deletes’ or previously submitted codes that were false or wrong, and had caused overpayments to the defendants by the federal government.”
The complaint continues: “Plaintiff was very upset, and knew, based on her years of experience in the job and knowledge of the CMS online manual and regulations that this directive by defendants would result in her failing to do a critical part of her job to ensure full compliance with federal laws and regulations, by forcing her to turn a blind eye to erroneous and unsupported diagnosis codes previously submitted and storied in the CMS system.
“Plaintiff knew that this directive violated the law, and that she and her fellow coders were being required to violate the law by her superiors.
“Plaintiff confronted her direct supervisor, Nancee Van Liere, and asked her does this mean that ‘I cannot submit any deletes,’ meaning that she could not submit anything but ‘adds,’ to verify her understanding that she was being told to break the law.
“Van Liere told plaintiff yes, that her understanding was correct.
“Plaintiff said to Van Liere that she would not commit fraud, meaning she would not ignore needed ‘deletes,’ as required by federal law.
“Van Liere agreed that she would not ask plaintiff to ‘commit fraud’ and that she had conveyed her own concerns about this directive to her own superiors.
“Van Liere told plaintiff that her two direct supervisors, Smith and Wayne Wilson, were informed of both plaintiff and Amber Pope’s objection to the violation of the law, but that the two men simply told Van Liere to tell the two of them to follow their instructions.”
Poffinbarger say she “could not bring herself to violate the law and CMS regulations, so when she saw needed deletes, or unsupported diagnosis codes, she deleted them anyway.”
She adds: “At various times, Smith and Wilson changed their directives, and issued spreadsheets of what they deemed ‘suspect lists’ of codes and ordered plaintiff and co-workers to look for possible ‘adds’ to a variety of different lists.
“Management focus was only on ‘adds’ and that was clear … and plaintiff was told to ignore previously identified lists of subscriber groups where needed deletes would be found …”
Poffinbarger says that when she and others “spoke up” at a meeting, “Wilson acknowledged the risk of what they were doing in ignoring the needed deletes by CMS rules, but claims that he would be the one to take responsibility for any blame.
“Wilson said to just ‘not worry about’ those records.
“Plaintiff and other employees asked about what would happen to these ‘deletes,’ and Wilson replied that if she did not like the direction that the company was going, she could feel free to find another job.”
Poffinbarger says that she and a co-worker, Amber Pope, took their concerns to their direct supervisor, Van Liere, saying that “there were ‘hundreds of deletes’ that by law, had to be deleted per DMS regulations ad law, sitting in the medical record files outside her office.”
“Both women, plaintiff and Pope, stated that they would not commit fraud or break the law, and began to cry, as did Nancee Van Liere. …
“Nancee Van Liere cried too, and said that this directive was coming from the ‘Third Floor’ or executive suites for defendants, and that they had to do what they were being told.”
Poffinbarger says she told Van Liere “that she did not ‘look good in orange,’ and refused to go to jail for anybody.”
She says Van Liere “told both women that she ‘took very detailed notes’ and that she did not agree with these directives but that she would make sure that they did not take the fall for this.”
Finally, Poffinbarger says, she called the CMS hotline, on Jan. 20 this year, “and asked what she needed to do to report fraud in a Medicare Advantage program, and gave her name and number to CMS.”
She says that Smith and Wilson fired her and four other coders on Feb. 3.
Poffinbarger says she refused to sign the severance agreement the company gave her, and that the company “falsely advised the unemployment agency” that she had signed it, apparently complicating, or making impossible, her attempt to get unemployment benefits.
Poffinbarger seeks lost wages and benefits and punitive damages for whistleblower violations, retaliation, violation of public policy, loss of opportunities and reputation, emotional distress, and costs.
The only defendants are Priority Health and Priority Health Managed Benefits.
Poffinbarger is represented in Kent County Court by Eugenie Eardley of Cannonsburg.