PPH Medicaid fraud case, part 2: patient-specific abuses

Planned Parenthood Clinic Sign

The nitty-gritty of exactly how Planned Parenthood flouted the law.

In my previous article, I summarized the lawsuit brought against Planned Parenthood of the Heartland (PPH). I also gave some background on the woman who filed the suit, Susan Thayer, a former manager of two clinics. In this article, I’ll be focusing on the first of three main groups of fraud schemes within the suit. If you have not yet read the previous article, I recommend doing so first. You can find it here:

From at least January 1, 1999, to the present and continuing, Planned Parenthood, acting through its officers, agents, and employees, including Jill June, CEO of Planned Parenthood, combined, conspired, and agreed together and with each other and with others not named herein to defraud the United States and the State of Iowa by knowingly submitting and/or causing to be submitted […] false, fraudulent, and/or ineligible claims for reimbursement […] and knowingly using, or causing to be made or used, false records and/or statements material to false or fraudulent claims. […] Planned Parenthood engaged in three fraudulent schemes, which are detailed herein,” reads the suit.

The first group of schemes is the most patient-specific, as it not only involves fraudulent charges, but the safety and privacy of patients, which Planned Parenthood disregarded by “the making, in violation of the applicable […] laws and regulations, of false, fraudulent, and/or ineligible claims […] for reimbursement from Title XIX-Medicaid funds for oral contraceptive pills (herein “OCPs” or birth control pills”) (i) never delivered to the patient; (ii) dispensed to a patient without a physician’s order or prior to a physician’s order; (iii) dispensed to a patient at levels not medically reasonable or necessary and/or constituting “abuse or overuse” and/or not consistent with professionally recognized standards of care and practice; or (iv) dispensed without the patient’s knowledge or consent and/or without having the patient undergo periodic examinations or new annual exams as required.

Planned Parenthood is required “to maintain clinical and fiscal records necessary to fully disclose the extent of services, care, and supplies furnished to Medicaid members” and to document:

  • The medical necessity of the services.
  • That services provided are consistent with the diagnosis of the patient’s condition.
  • That services are consistent with professionally recognized standards of care.

Services “covered by Medicaid shall:

  • Be consistent with the diagnosis and treatment of the patient’s condition.
  • Be in accordance with standards of good medical practice.
  • Be required to meet the medical need of the patient and be for reasons other than the convenience of the patient or the patient’s practitioner or caregiver.
  • Be the least costly type of service that would reasonably meet the medical need of the patient.
  • Be provided with full knowledge and consent of the patient or someone acting in the patient’s behalf[.]”

Lastly, the Iowa All Provider Manual states that “[p]ayment will not be made for medical care and services:

  • That are medically unnecessary or unreasonable.
  • That fail to meet existing standards of professional practice, [or] are currently professionally unacceptable…
  • That are fraudulently claimed.
  • That represent abuse or overuse.”

On all above counts, Planned Parenthood has violated the law, based on Thayer’s evidence. The central point of evidence is Planned Parenthood’s patient records system, which utilizes a centralized computer network that links to the Des Moines office and is accessible by all managers. Thayer, given her position at two clinics, “in compiling and processing bills for medical services or supplies rendered to patients[,]” had access not only to her clinics’ patient information, but to all PPH patients’ information. This centralized system “is based upon input from each Planned Parenthood clinic and includes information or data relating to each patient and medical services or supplies provided to each patient.” That data from each visit by a patient (or “encounter,” as Title X refers to it) is sent to the Iowa Medicaid Enterprise and the Iowa Family Planning Network for reimbursement.

What Thayer noticed in recording and reviewing billing information was that PPH was having its employees use the Medicaid system as an income source in ways that not just were illegal uses of tax-payer funds, but also failed to provide safety, privacy, and standards of professional medical care to patients. These practices were “in accordance with the directions given to Relator [Thayer] by her supervisor, Planned Parenthood Regional Director Todd Buchacker[.] … By virtue of her positions … , Relator had access to and frequently viewed billing information, patient charts, and records for patients at all other Planned Parenthood clinics[.] … In this way, Relator could and often did view entries in each patient billing record, including patient case histories, medical services and prescription medications provided, test and lab results, staff chart notations, charges to patients and payments credited to the patient’s account whether made by patients or others, including insurers, Iowa Medical Enterprise and/or Iowa Family Planning Network, and donations to Planned Parenthood.”

Starting in 2006, one of these new income sources was the “C-Mail Program, which was designed to provide birth control pills or patches to all patients and in particular, due to its revenue potential to Planned Parenthood, to Medicaid-eligible patients. During this phase of Planned Parenthood’s C-Mail Program, Medicaid-eligible women seeking birth control pills … would, following an initial examination, be prescribed a three menstrual cycle supply (i.e. 84 birth control pills) of birth control pills and would sign a consent form approving their participation in … C-Mail … and authorizing Planned Parenthood to use the U.S. Postal Service to mail birth control pills to addresses specified by the patient.” These initial exams and prescriptions, in many cases, were not performed or approved by a primary physician, in violation of above laws. Additionally, “many [PPH] patients chose not to participate [in C-Mail], in many cases because these patients, ostensibly for personal reasons, did not want birth control pills or patches to be mailed to their homes or to their dormitories.”

“Because Planned Parenthood’s revenues were not sufficient to cover its abortion-related and other expenses, representatives […] began to seek ways to enhance Planned Parenthood’s revenues … [therefore, PPH] charged its Health Services Management Team (herein “HSMT Team”), made up of, among others, Planned Parenthood CEO Jill June; Planned Parenthood Vice President of Health Services & Education Penny Dickey; Planned Parenthood’s Regional Directors Todd Buchacker, Deb Lord, Jennifer Warren-Ulrick, and Sheri Sperlich, to develop methods to enhance revenue to Planned Parenthood to cover this shortfall.”

They determined that allowing patients to opt into C-Mail meant many would opt out, which left PPH unable to bill Medicaid for birth control, cutting a major potential cash source. Those who did opt in often received OCPs for ONLY 4-7 menstrual cycles and didn’t renew the participation/prescription. They realized that PPH “could increase its revenues by [switching] the C-Mail Program to a mandatory program [emphasis mine] whereby patients were supplied OCPs for a full year.” This change enabled PPH to make $26.32 per cycle, or $342.16 per year, per patient prescription of Tri-Cylclen Lo, Planned Parenthood’s preferred OCP. Within months of creating C-Mail, PPH had converted the program so any female who visited them was sent OCPs to her home or dorm “usually without the advance knowledge and/or written consent of the patient and/or without informing the patient that the patient could affirmatively decline to participate.”

The mandatory program became a competition amongst PPH clinics to see who could get more women into the C-Mail Program. Using the current numbers as a baseline, PPH established a percentage-increase goal to get 7,667 enrolled by October 31, 2008. The automatic enrollment coupled with a competition incentive to grow the program led to at least 7,000 females being enrolled by December 31, 2008, meaning at least $2,395,120 per year in new revenue from Medicaid funds. This subsidized PPH’s basic needs and operations, among other expenses, including abortions. As the suit states, “in most cases no physician or other qualified clinician participated in the initial exam of the patient.”

With Planned Parenthood’s “favorable arrangement with the manufacturer,” Tri-Cyclen Lo was the preferred OCP and was not only handed out during the initial visit by a patient, but also mailed to her, giving her a double supply and consequently billing Medicaid twice for the first cycle. “In this manner, Planned Parenthood created a medically unnecessary surplus of at least 120.96 doses [per patient per year], resulting in overcharges … of at least $113.70 per patient. Moreover, … most patients were neither examined by a physician or other qualified physician at the initial patient examination or at any time thereafter for at least one year or more after the initial OCP prescription[.]” Those who did go in for a yearly exam generally had a Hormonal Option without Pelvic Exam or HOPE, which involved a non-medical employee who assists in filling out a patient form and doing a blood pressure check. Following the HOPE, another year’s worth of OCPs would be prescribed through C-Mail. “In some cases following a patient’s HOPE examination, sometimes days later, an advanced registered nurse practitioner (“ARNP”) would appear at the Planned Parenthood clinic [where the exam occurred] and sign off on all OCP prescriptions which had already been given to patients.”

“Planned Parenthood did not contact patients to confirm that patients wanted and/or needed OCP prescriptions to be refilled and mailed. In many cases, patients had moved from the address [and gave no forwarding address]. In these cases, OCPs mailed … were returned … to Planned Parenthood. Notwithstanding these facts, Planned Parenthood did not credit or otherwise make an adjustment to its billings or reimbursements [from Medicaid]. In fact, [PPH] instructed its staff to return OCPs that had been returned in the mail to the inventory of OCPs and to reship such returned OCPs to future patients, thereby effectively billing [Medicaid] at least twice for the same OCPs.”

This unsolicited dispensing of drugs to people’s homes, dorms, and campus post offices enabled family, roommates, and mailbox sharers to see that the women were getting regular packages from PPH, violating the privacy of even those who used OCPs and creating conflicts for those opposed to taking them. “Patients complained to Planned Parenthood, including to Relator when she managed Planned Parenthood’s clinics, that these patients had requested [that they] cease mailing OCPs to them. Some of these patients reported that the unsolicited delivery of OCPs to a patient’s home or dormitory caused severe strain on the patient’s relationships. Notwithstanding such requests from patients, [PPH] continued to mail such patients a three menstrual cycle supply of OCPs every 63 days for at least one full year from the date of the initial patient examination.

“On several occasions, physicians in the Iowa area, upon becoming aware of Planned Parenthood’s practice of prescribing birth control without an interim comprehensive examination of the patient, objected to Planned Parenthood or to others about this practice and stated that this practice was below the medical standard of care. [PPH] justified its practice by contending that OCPs would soon be available over-the-counter and that [they] therefore considered it acceptable to prescribe and distribute OCPs in this manner.” As one can imagine, it doesn’t matter that a drug may become available over the counter in the future, but only that it is currently not, which means it requires a prescription and physician involvement. This justification by PP is also exposed in Live Action’s undercover videos and PP’s public statements that they failed to report the purported sexual assault of minors immediately (or at all) because they suspected that Live Action might be behind them. The law does not provide for PP to fail to comply if they feel justified in doing so.

“From mid-2006 through and after December 31, 2008, [PPH] prescribed and dispensed OCPs to patients arbitrarily enrolled in the program, totaling at least $3,316,320 per year as a result of which [they] submitted false, fradulent, or ineligible claims to [Medicaid] and/or Iowa Family Planning Network of $824,768.78 or more per year.”

In summary, the suit states that in light of the above, PPH’s practices were medically unnecessary and/or unreasonable, failed to meet existing standards of practice, were professionally unacceptable, were fraudulently claimed, represented abuse or overuse, and resulted in the distribution to patients of OCPs that were not written or approved by a primary physician.

For information regarding the second fraud charge group, please see my next article in this series.

To Top

Send this to friend