24-year-old Hannah A. is “playing tag” in the front yard at 3 a.m. one cold February Sunday night during a rain storm. She slips, falls, and horribly breaks both bones in her left leg. Incidentally, she also has a nasty burn on her right forearm that she says is from a hot water scald. Though our nurses recognize her from two ED visits the prior two days, there is no record in our electronic health record of these prior visits. The night shift is busy so we move along, treat her injuries, and admit her to the hospital. Interestingly, before Hannah A. departs for the inpatient unit, a woman identifying herself as Hannah A’s mother calls the ED to inform the emergengcy physician that Hannah A. has been in jail, abuses pills, and should probably be in jail again.
At 5:30 a.m., a retail pharmacist calls our ED to alert the doctor that someone named Ann L. called his pharmacy to request that no medications be filled using her Medicaid card without requiring photo I.D., because someone else is using her Medicaid card to get pain pills. Since the purportedly false Ann L. has been to our ED twice in the past two days, he thought we should be aware of this.
This occurrence sparks a new realization. Hannah A. with the broken leg and burned arm had been in our ED the prior two days but we couldn’t find records of her visits. What a curious coincidence, the EP thinks. So he now looks up the medical records for both Ann L. and Hannah A. Remarkably, these two individuals have been going between two different EDs in our health system over the past six weeks for two recurring complaints: eye injury and hot water burn to forearm. Ann L. is particularly special since she was both a 3rd trimester pregnancy patient on the labor hall and a non-pregnant patient with a burned arm in the ED – all within a 24 hour period!
Are you confused? I was.
So, the EP goes up to the 4th floor and inquires of Hannah A., “Are you Hannah or are you Ann”? Without any hint of hesitation or concern, Hannah A. denies any knowledge of Ann L. and denies any association with the events above. The ED doctor politely informs her that the police will be coming shortly to clear up this unfortunate confusion.
Shortly after this interaction, a woman identifying herself as Ann L. calls the house administrator to inform her that someone is falsely seeking medical care using her identity. Sort of ironic (isn’t it?) that this phone call came so quickly after the EP spoke with her and informed her of the imminent police visit.
After the drama that then unfolds on the inpatient unit between the patient and the police, the following actual series of events come to light:
Hannah A. really is Hannah A. and she has an outstanding warrant out for her arrest. Hannah A. has been pretending to be Ann L. in order to seek medical care under false pretenses to fraudulently obtain narcotic pills paid for by the state Medicaid program. Hannah A. has been self-inflicting hot water scald injuries to her forearm to obtain narcotics.
Apparently, Hannah A. and the real Ann L. live a couple doors down from each other in the same apartment complex. Ann L. agreed to let Hannah A. impersonate her on the following terms: a) that Hannah A. share some of the narcotic pills with her so she could give them to her husband and b) that Ann L. share some of the financial proceeds from the sale of the pain pills with her.
Remarkably, it seems a lot of people like to be Ann L. and it turns out that Ashley M. has also been involved in this circle of friends. Ashley M. has been the person poking herself in the eye to create corneal abrasions in order to fraudulently obtain narcotics in the ED (paid for by the state Medicaid program).
As it turns out, Hannah A. and Ashley M. initially fulfilled their half of the bargain by sharing their pills and profit with the real Ann L. After a while, though, the real Ann L. began getting more ambulance and ED bills, but she was not receiving her portion of the pill and profit proceeds. Understandably, this breach of contract upset the real Ann L. so she began calling pharmacies and hospitals to try to put an end to the misuse of her identity and Medicaid coverage.
So, why did all this unravel, you may ask? On that cold and rainy February night on which this all came to light, the police had knocked on Hannah A.’s front door to serve her a warrant for arrest. Naturally, this upset Hannah A. so she jumped out of her second story apartment window to escape. With two bones in her leg broken in four places, she then sought medical care for an entirely legitimate reason, using her true identity.
One day later, Hannah A’s leg has been surgically repaired and she is receiving excellent, high quality American health care services at a Top 100 hospital. The doctors and hospital, of course, will never receive any compensation for their efforts and costs. This excellent care is guaranteed to all Americans at no cost to them (but enormous cost to doctors, hospitals, and other paying patients) compliments of EMTALA.
At least four people – Ann L. and her husband, Hannah A., and Ashley M. – will be charged and arrested. If one more person is found to be involved then this becomes a Federal case with even more severe consequences to the criminals and even more cost to society.
This is a sad but true story of prescription drug abuse unintentionally enabled by the U.S. Medicaid program. This broken system fosters extreme fragmentation in health care delivery and sticks doctors and hospitals with the costs and liabilities of providing care without hope of remuneration.
We can and should do better.
Nearly 200 readers responded to this month’s Standard of Care scenario on a diagnosis of prostatitis. Read the verdict, plus William Sullivan’s case analysis, in the May issue of EPM.