Whistleblower in Maxim case is role model for fraud detection

Something didn't look right. Maxim Healthcare nurses were showing up at Richard West's house according to one schedule. But Maxim was billing the government according to another.

West complained to the state: The company was charging for hundreds of hours of work it never did. Officials blew him off, he said. He alerted Medicaid, the state and federal program that paid for his care. Nothing happened.

He told a social worker. She expressed concern, but did nothing. But West, a Vietnam vet with muscular dystrophy, kept pushing and pushing, building a giant, accusatory snowball that landed last week — eight years later — on Maxim's Columbia headquarters.

Maxim has signed a criminal and civil settlement related to allegations that it schemed to rip off $61 million from state and federal governments, law enforcement authorities said last week. The company is paying $150 million in penalties and recompense. Eight former Maxim employees so far have pleaded guilty to felony charges in several states.

If Washington is as serious about fighting medical fraud as it pretends to be, it will recruit an army of Richard Wests to burn off leeches like Maxim. Nobody is in a better position to see fraud than patients, who can check the care they receive against what's on the invoice.

Now that West has shown that patients can get rich in the bargain, there's plenty of incentive. Not that his motivation was his $14.8 million share of the settlement. Anger was. He didn't even know about such whistleblower rewards at first.

"Somebody decided to make a profit on my disability," West said in a telephone interview. "This is your country. You see fraud, you should turn them in. That is part of being an American."

Whistleblower rewards under the federal False Claims Act have been around since the Civil War. The recent caseload has been dominated by allegations of Medicare and Medicaid fraud, which costs taxpayers billions of dollars a year.

In almost every instance, the person who alerts law enforcement is a corporate insider, not a patient. West's information in the Maxim case was so compelling, however, that the government credited him as the "original source," with independent and direct knowledge of the fraud.

He kept spreadsheets on the gaping discrepancy between the hours Maxim nurses spent in his home north of Atlantic City, N.J., and the hours Maxim billed Medicaid. Eventually he documented more than 700 hours of bogus charges, according to the New Jersey attorney general.

After a couple months of detective work, West got in touch with Baltimore lawyer Robin Page West (no relation), who specializes in whistleblower lawsuits. Together they built a case, filed it under court seal in 2004 and turned it over to law enforcement. And waited.

West, 63, speaks precisely but with difficulty, in a high-toned voice. He says he commanded an Army track vehicle with 40 mm guns in Vietnam in 1968 and 1969 — the deadliest years of the war there. Yet biding his time while investigators built their file, he said, "was the hardest thing I've ever done."

The Feds broadened their investigation from West's case. They started looking at Maxim's business across New Jersey, then in another state, then in another. They kept finding new evidence of wrongdoing — stretching from 2003 to 2009.

Because the case was under seal, West couldn't talk about it. Because sometimes he had trouble getting care, he suspected word had gotten out that he was a troublemaker. Occasionally viruses made him severely ill.

He was afraid of dying and leaving his son with a big legal mess. Worse, he feared that if the whistleblower were no longer alive, the case would be dismissed.

But the vein of irregularities he had uncovered was so deep it took this long for the government to go public. West's lawsuit was unsealed Monday.

One man. One wheelchair, one respirator, one computer. And an outrage that somebody was ripping off the program that was keeping him alive.

The Centers for Medicare and Medicaid Services in Woodlawn ought to make West at least as famous as Steve Bisciotti, the Baltimore Ravens owner who is a Maxim co-founder and shareholder.

(Maxim told The Baltimore Sun that Bisciotti never exercised day-to-day control. The company and its new CEO have agreed to a long set of reforms, and Maxim has accepted responsibility for conspiring "to execute a scheme and artifice to defraud health care benefit programs," according to settlement documents.)

Put Richard West in TV commercials. Make a DVD for Medicare patients. Thievery such as Maxim's is one reason budget deficits are out of control, but privacy laws make it difficult for journalists and law enforcement to investigate health care fraud. They can't scan people's bills.

Patients don't have that problem. It's time for the Department of Health and Human Services to crowdsource fraud detection. Breathe new life into the Senior Medicare Patrol, which trains beneficiaries to identify scams. Last year the group was credited with recovering a miserable $39,000 in savings for Medicare and Medicaid, according to government records.

The agencies that run these programs and the patients that benefit from them have a duty to do better.

West plans to donate much of the reward money to disability causes. When he first found out he could get paid for turning in Maxim, "I thought, gee, maybe I can make a couple thousand dollars," he says. "Maybe I can fix my van, fix my house. This is great."

Now, he says, "Forget the money." Making the system work better "is the most rewarding thing I've ever done." Turning West into a crowdsourcing role model could multiply the rewards for everybody.


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