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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

SEPTEMBER 2002 NICA NEWS

GOLD RECORDS

Laura and Charles Kruse

Laura and Charles Kruse from South Sioux City, Nebraska really came to the call for need when they assisted a Nebraska veteran. The gentleman was increasingly ill and unable to get an appointment with the Veteran's Administration Hospital. Laura made contacts with the NICA program office and the area Veteran's office for assistance. Through the Kruse's good efforts, the gentleman was able to get an appointment right away at the Veteran's hospital and get bus transportation for the out of town trip to be provided by the hospital. It was also arranged that should his medical condition continue to deteriorate, the local hospital will care for him since the VA hospital is too far away. LAURA AND CHARLES MADE A DIFFERENCE! Our NICA efforts can make a strong impact on someone's life.

Sharon Strong
South Central Area Agency on Aging

Former Kearney cardiologist Rajitha Goli has been convicted in federal court of operating a health care fraud scheme in Kearney and Sargent. Goli pleaded guilty to health care fraud, after she was charged with operating the scheme in the mid- to late-1990s. The scheme involved the administration of medically unnecessary intravenous heart therapy to approximately 92 elderly people. As part of her plea, Goli will serve a year in federal prison, make restitution, and cooperate in the investigation of other health-care violations. Sharon Strong, the NICA regional representative in the South Central region, was an important part of helping catch Dr. Goli.

In December of 1998, clients contacted Sharon's office in reference to billing/claims questions. In reviewing the EOMB, Medicare Supplement Payment records and the doctor's bill, it was necessary to open a case for extensive investigation. Numerous attempts to reach the doctor's billing office were unsuccessful. Requests were made to Medicare Part B of Kansas for copies of all Explanation of Medicare Benefits for a given period of time. These copies (numbering in the hundreds) were then sent to the Medicare Supplement Company. While these efforts were being made, Sharon continued to contact the doctor's billing companies. When she finally made contact she learned that these billing statements toll free telephone numbers were collection agencies. As soon as she made contact with one of the collection agency's representatives and was making progress, the collection agency name and phone number changed.

As Sharon gathered information on this case she knew something was seriously wrong, yet she had to keep all information confidential. That meant she could not tell neighbors and local seniors not to pay the potentially false bills.

In early January of 2000, three clients brought in a letter they had received dated 12-23-99. The trigger statement was, "Dr. Goli is making a special offer to discount the above balance by 50% if paid to us by 12-31-99."

In January 2000, Sharon wrote the Federal Bureau of Investigation (FBI) as to the 50% offer. She communicated with the FBI off and on from that date through the FBI's investigation including a visit in person in the spring of 2002. During the in-person visit Sharon shared with the FBI two large boxes of files on this case that had been gathered for over three years.

Dr. Goli was eventually charged with falsely billing federal and state government through the Medicare and Medicaid programs and private insurance companies. The fraud scheme also involved other false billing practices and related kickback activities, with the total estimated loss at approximately $1 million.