Physician Accuses ProCare of Falsifying Medical Records

In a case that raises new questions about California’s ability to monitor medical care for millions of Medi-Cal enrollees who are being steered into HMOs, a San Diego physician has alleged that a managed-care company falsified medical records to pass a state inspection.

Dr. Dianna L. Norman made the detailed accusations in a complaint to state health officials and in interviews with The Times. Norman claims that employees of ProCare Inc., a San Diego health-care company, instructed her office staff to alter and forge patient logs and medical charts to cover up shortcomings and enhance its prospects for winning more Medi-Cal business.

Norman said the records were falsified in preparation for a January 1995 audit by the state Department of Health Services. The audits are the main tool by which the state monitors the quality of health care available to Medi-Cal enrollees.

Dr. Robert W. Dukes, ProCare’s owner and CEO, strongly denied Norman’s allegations. “We don’t do that at all. It’s illegal and there would be nothing to gain by that,” he said in a telephone interview late Wednesday.

Among other allegations, the state is investigating Norman’s claims that ProCare employees altered patient charts to falsely state that women had received mammograms, breast exams or Pap smears that had not actually been given. In the complaint and interviews, she also said they backdated files to make it appear that patients had been notified about missed appointments and fabricated child lead poisoning and nutrition questionnaires and placed them in pediatric files.

Norman also contends that ProCare officials were able to obtain the names of patients whose medical charts would be reviewed before the audit took place. To protect against possible fraud, the state mandates a “blind” audit procedure: HMOs and doctors are not supposed to be told beforehand the specific patient files to be reviewed.

A senior department official, who agreed to speak only if he wasn’t identified, confirmed that the agency is investigating the allegations against ProCare. Norman said state investigators have interviewed her and members of her staff.

Norman, who had a contract with ProCare to treat Medi-Cal patients, filed her complaint in November, shortly after ProCare canceled the contract for what it called her financial problems.

Dukes said, “She’s been bitter ever since.” He suggested that Norman’s charges were motivated by a rival health-care company. “She’s being coached by another health plan,” he said, without elaborating.

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The audit took place at a crucial juncture for ProCare, a privately owned managed-care company that provides medical services for nearly 40,000 Medi-Cal enrollees in San Diego, San Bernardino, Los Angeles, Orange, Riverside and Santa Clara counties. Medi-Cal is the state’s version of Medicaid, the federal medical program for low-income families.

At the time of the audit, state health officials were considering ProCare’s bid--ultimately unsuccessful--for a key state contract to serve Medi-Cal enrollees in Stanislaus County. ProCare was also deep in negotiations with another state agency over its application for an HMO license that would have enabled it to significantly expand its Medi-Cal membership. State regulators granted a license to ProCare’s owners to create an HMO called the Great American Health Plan.

The allegations come as the state presses ahead with a controversial plan to force Medi-Cal enrollees into health-maintenance organizations. Some health-care advocates say some patients will be forced into poor-quality HMOs, and that state regulators have often been slow to act against such firms.

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The department’s principal means of monitoring medical care for Medi-Cal patients has been an annual on-site audit of selected doctors’ clinics and pharmacies under contract to an HMO. Audits look at everything from childhood immunization rates and the timeliness of specialist referrals to whether audiometers are properly calibrated.

ProCare had a history of run-ins with regulators over its medical care.

For four years in a row, from 1990 to 1993, state audits had found “major deficiencies” in ProCare’s quality of care, records show. A major deficiency is defined as a “pattern of noncompliance . . . that has the potential to endanger patient care or operations.”

In March 1993, regulators barred ProCare from enrolling new Medi-Cal recipients, citing the company’s “continued failure” to comply with state licensing requirements and “systemwide problems.” In September 1994, the state withheld about $200,000 in payments to ProCare for failing to meet quality standards.

The state also offered ProCare an inducement to improve: The company could get half the money back if its 1994 audit showed enough improvement.

The incentive apparently worked. ProCare’s audit for 1994--the same one that Norman’s complaints involve--was much-improved. ProCare got half the $200,000 back.

In its audit for 1995, done early this year, ProCare again received high marks from regulators.

Jay Zybelman, ProCare’s executive vice president, said the firm has taken aggressive steps to improve oversight over medical quality. And state health officials have recently praised the plan for its quality assurance programs, state records show.

In a Dec. 2 letter, Dukes notified Norman that ProCare employees would visit her office weeks before state investigators arrived to help with “clerical-type activities that can make a difference in the auditors’ results.”

According to Norman, ProCare told her several weeks before the audit that it had compiled a list of roughly 130 patients whose medical charts would be among those audited. Norman says she has more than 2,000 patient files. But because the state’s policy is to make certain criteria known to providers ahead of time, largely to help expedite the auditing process, it is possible to significantly narrow the list of charts likely to be audited. For example, investigators planned to review only patients who had at least three physician “encounters” during the audit period.

“They pulled 130 patient charts, and they knew what the state was looking for,” Norman said in an interview. “They would just go through the charts, and if the right information wasn’t there, they put it in or made it up.”

In late December, Norman said, ProCare officials gave her a fax with a list of 10 adult and 10 pediatric patients that it said “for sure” would be audited. All the patients’ charts on the list were, in fact, audited weeks later, she said.

Norman added: “I asked them, ‘How do you know the exact [patient charts] they’re going to ask for?’ And they said, ‘We have friends in Sacramento.’ ”

Another physician, Dr. Albert Giannini of Escondido, gives a similar account of ProCare employees obtaining the names of specific patients to be included in the January 1995 review.

“ProCare had a list of 50 patients’ names and they said they were told the names by the state,” Giannini said in an interview. He said ProCare employees spent “about a month” in his office before auditors arrived.

Giannini, who like Norman no longer has a contract with ProCare, said he knew of no instances in which ProCare employees tried to alter information in his patients’ charts.

In an interview, Norman and her office manager, Dana Dare, said Norman didn’t become aware of ProCare’s activities until Dare informed her that ProCare employees were directing the staff to make false entries on medical documents. They described a deliberate process in which ProCare employees had the doctor’s staff use different colored pens to make it look as if chart entries had been made on different days.

Norman conceded that she did not order ProCare employees to leave her office or report the activities to state health officials until nearly 10 months later, after ProCare had canceled her contract.

Why didn’t she act sooner?

“In an ideal world, that’s what you would do,” she said. “But these people [ProCare] have you in a contract that [accounted] for 25% of my practice.” She said she was afraid that if she spoke up, ProCare would retaliate by dropping her contract.

ProCare did cancel Norman’s contract last October. In a letter dated Oct. 25 informing her of the termination, ProCare CEO Dukes wrote that Norman “was no longer in a financial state . . . to continue to treat patients at your clinic.” Norman said she was behind in rent payments on her medical office and had asked ProCare for temporary financial assistance. The rent dispute was resolved a short time later, she said.