Indian Health Clinic Fund Misuse Claimed

The administrator of a Lakeside-based Indian health clinic is under fire from federal officials for allegedly mismanaging more than $10,000 in public health funds.

Orin Tonemah, executive director of the Southern Indian Health Council, was scored by examiners for the Indian Health Service office of the U.S. Public Health Service for not following federal guidelines when referring patients to other health care providers, such as private doctors and hospitals.

Tonemah claimed extenuating circumstances prevented the guidelines from being followed. Those guidelines call for patients who need services outside the health clinic itself to first apply for “third-party” insurance coverage--such as Medi-Cal, Medicare or San Diego County’s medical services program for indigent adults--to pay most or all of the bill.

In the rare instance when an Indian would not qualify for coverage under one of those plans, the clinic would pick up the entire bill for medical coverage, using federal Indian Health Service funds.

But a Indian Health Service (IHS) review team claimed that in at least 20 cases it examined, Tonemah was found to have authorized his clinic to pay for health care services by outside health care providers without first having the patient apply for third-party insurance coverage, thereby using federal Indian health care funds to pay costs that might well have been covered by other public agencies, said Ken Jamison, a contract health services officer for the IHS regional office in Sacramento, according to the examiners.

The clinic, on the Barona Indian Reservation in Lakeside, was established in 1983 to provide primary health care for members of federally recognized Indian tribes living within its service area of East San Diego County. With an annual budget of $1.5 million, it employs a staff of about 40 and sees about 500 patients a month.

The budget includes about $300,000 in federal Indian Health Service funds earmarked to help pay for medical services received by Indians based on referrals by the clinic to outside health care providers.

Jamison said the alleged abuses of the IHS funds were uncovered several weeks ago during a review of the clinic’s 1986 operations. He said the instances where patients were allowed to bypass applying for third-party insurance may have cost the clinic “thousands” of dollars.

He declined to elaborate, but one member of the review team said it reviewed a random sampling of 20 purchase orders for outside services that had been authorized by Tonemah and said that, in each case, the patient receiving those services had been excused by Tonemah from applying first for Medi-Cal, Medicare or the county’s indigent care coverage.

The purchase orders were for services ranging “from $20 to $10,000,” the reviewer said.

“We didn’t do a 100% audit of the (outside contract) purchase orders but, based on the sampling that we did look at, it would appear that maybe $50,000 or $60,000 in IHS funds were mismanaged,” said the reviewer, who insisted on anonymity because he said he felt uncomfortable discussing the report, which has yet to be presented to the health council’s board of directors.

IHS administrators do not intend to discipline or sanction Tonemah or the clinic, said Jim Mitchell, chief of contract health services in the IHS headquarters in Rockville, Md.

“This is not a review that would make a judgment of criminality or that kind of wrongdoing,” he said. “But we have written criteria that we assess tribal and IHS programs against, and one of the things we look for is documentation of persons using third-party resources. We pull a sampling and analyze whether they are.

“In general, we can do a significantly better job of using third-party resources (to pay for health care for Indians), so that Indian people are then able to get more care with IHS money.”

Tonemah said he had not yet seen the IHS review of his program’s management, but said that each time he authorized clinic money to pay for outside health services, “there were extenuating circumstances.”

He said he authorized his clinic’s doctors to send patients to private doctors or area hospitals in emergency situations without first making the patients apply for Medi-Cal or other coverage because the patients’ situations were too serious to make them wait two days or more before receiving third-party coverage.

He said the clinic would then help the patient apply for third-party coverage retroactively, as is permitted by federal guidelines.

But the IHS reviewer said the agency’s examination of Tonemah’s records showed no instance when his staff had made a retroactive application for third-party coverage.

“We never saw any extenuating circumstances on any of the authorizations by Tonemah that we reviewed. There just weren’t any,” the reviewer said. “It looked to us that he simply said to people, ‘OK, we won’t make you go through the system. Go directly to the referral and we’ll pay the bill, period.’ And there was never any indication that third-party coverage was applied for after the fact.”

Tonemah said he disagreed with the reviewer’s interpretation of the review and said: “I have to use my judgment as director when I make decisions, and I stand by my decisions.”

Frances Shaw, chairman of the Southern Indian Health Council’s board of directors, said the directors are split in their support of Tonemah and his management of the health clinic, based on the IHS review.

“Our executive director is a person who is concerned about people, patients, and that’s why he gets into trouble,” Shaw said. “He’s too big-hearted. Anyone can go in and talk to him and say this and that and he’ll say, ‘OK, go ahead and do it,’ even though the regulations say you can’t.

“The IHS is giving us a chance to get our act together, and that’s where things stand. I think they’re just hoping we can get this program under control, and I’m hoping that, too.”