Kaiser Permanente and several of their high ranking employees allegedly tried to submit false claims to Medicare, according to a former employee who says she discovered and wanted to report the fraud.

These false claims to Medicare were allegedly asking for compensation for services or medical products that were not given by a trained medical professional, or were not delivered at all, says the employee in her lawsuit against the medical provider.

Plaintiff Yvette J. says she had previously worked at the Kaiser Permanente Los Angeles Medical Center before being fired for trying to prevent her superiors from submitting false claims to Medicare.

Yvette alleges that the false claims pertained to the Kaiser Permanente’s Special Needs Program. Yvette says that the false reports and statements were made to maximize Medicare compensation.

Not only were the false claims to Medicare inaccurate regarding patient information, Kaiser allegedly took no action to correct the claims even though Yvette had reported it to multiple levels of management.

Overview of Medicare Fraud Lawsuit

According to the lawsuit, Yvette had worked for Kaiser from April 2, 2012 to March 12, 2018, in its Continuing Care (Geriatrics) division as a Case Manager in the Special Needs Program (SNP).

Yvette says she worked with three to six other team members during her employment with Kaiser, who all helped administer and sort cases that could qualify for the medical insurance company’ Senior Advantage Medi-Cal Plan South.

Under the terms of the program, alleges Yvette in her lawsuit, eligible participants must live with a chronic or disabling medical condition, live in a nursing home or other medical facility, and must be eligible for both Medicare and state Medicaid benefits. Kaiser developed this program to help long term geriatrics patients who were receiving Medicare benefits.

Yvette says in her lawsuit that she and her team members were required to review in-home assessments and act as liaisons between care manages and the patient’s primary physician with Kaiser Permanente. Shortly after Yvette had started working for Kaiser, however, one of the LAMC SNP team members allegedly instructed Yvette “don’t talk.” Yvette says she initially did not understand what this meant, as her job required her to regularly communicate with clients over the phone.

The SNP team member allegedly instructed her to do this because LAMC SNP team members were not making phone calls to their patients and were not being reprimanded by management. According to Yvette, LAMC SNP team members were required to complete five assessments per day.

This strange behavior eventually led to Yvette to allegedly discover that Kaiser was submitting false claims to Medicare, with none of the LAMC SNP team being instructed to do their jobs — conduct calls with patients.

According to the Medicare fraud lawsuit, Yvette had told her superiors that LAMC SNP team members were consciously not making required telephone calls to patients but were still documenting that they had in their records.

Yvette then suggested that management review the phone records of SNP members to look out for any fraudulent activities. Yvette was then told to take her findings to Human Resources and was then told to stop monitoring the case management unit and to stop emailing about the allegedly fraudulent activity in the phone records.

In her lawsuit, Yvette alleges that the failure of the LAMC SNP team to conduct required follow-up with patients resulted in Kaiser submitting false claims to Medicare.

After reporting the alleged false claims to Medicare, Yvette says she she suffered major workplace retaliation including acts of sabotage and isolation. Yvette says she was eventually fired and even went to the police with these fraud allegations, which ultimately led her to file legal action under the False Claims Act.

This Medicare Fraud Lawsuit is Case No. BC-716042, in the Superior Court of the state of California for the County of Los Angeles, Stanley Mosk.