Whistleblower Says Medical Management Co. Improperly Denied Healthcare

SynerMed, a large healthcare management company, was hit with allegations that thousands of Californians were improperly denied Medicare and Medicaid claims.

An executive with SynerMed blew the whistle after she says she witnessed years of policies and practices that improperly denied healthcare benefits to low-income patients. The whistleblower further alleges that SynerMed hid violations by falsifying documents.

SynerMed works behind the scenes in the healthcare industry to provide administration services to medical groups and managed-care contracts. It is one of the largest physician-practice companies in the country, managing the medical care of approximately 650,000 Medicaid recipients in California.

Billions of taxpayer dollars go to companies like SynerMed to administer federal health care programs. Advocacy groups say that this situation exposes the lack of oversight of companies that profit off these taxpayer funded programs.

For years, alleges the whistleblower in a 20-page report, SynerMed engaged in “widespread, systematic” violations of healthcare law and denied healthcare to the lowest income Californians entitled to care under federal programs. SynerMed’s practices threaten the health and safety of members, warns the whistleblower’s report as reported by Kaiser Health News, who obtained a copy of the report.

According to the report, after the Affordable Care Act allowed SynerMed to expand, a small group of employees was tasked with a huge backlog of paperwork. The employees reported that they were instructed to falsify denial letters and commit other violations. Further, patients were not provided copies of the denial letters, but they were used to complete regulatory audits. The whistleblower report notes that these practices were described in training materials provided to employees and the employees said they faced intense pressure to complete the work.

A state regulator verified the allegations in the whistleblower’s report. “I think it’s pretty egregious actions on the part of that company,” the regulator said in an interview reported by the LA Times.

After the report was released to officials, SynerMed was hit again, this time with surprise audits and a state initiated investigation. As a result of the allegations that Californians were denied healthcare, SynerMed’s CEO announced the company would close.

Walmart whistleblower lawsuitState regulators have also warned insurance companies that thousands of Californians are in danger of being denied healthcare, including medically necessary services, because of SynerMed’s activities. Regulators are scrambling to figure out how many Californians are affected and may be in need of healthcare services that were improperly denied.

The whistleblower says that she felt pressured by her employer to drop her suspicions while investigating and compiling the report, but as she became increasingly concerned that patients were being improperly denied healthcare, she decided to press on.

While the federal government attempts to regulate the healthcare industry and investigate claims of improperly denied healthcare and fraud, it often takes employees within the organization to come forward. Healthcare companies that commit fraud or otherwise violate healthcare law rob patients and taxpayers who support federal healthcare programs.

Whistleblowers are provided protection from retaliation and loss of their job under the False Claims Act. Further, if a whistleblower is successful in identifying and stopping healthcare fraud, they can be entitled to a portion of the award.

If you are concerned about healthcare fraud, contact the attorneys at Bradley/Grombacher

Bradley/Grombacher is not representing the plaintiff in this lawsuit.