Fake mammogram results lead to indictment

A hospital in Georgia is facing many questions after a former employee was indicted for what authorities say was intentional fraud in entering negative results for mammograms that, in fact, had not been read by a radiologist.

A former hospital employee in Perry, GA, was indicted recently on 10 felony counts of computer forgery and 10 counts of misdemeanor reckless conduct, with prosecutors alleging that she entered negative results for 1,289 mammograms at Perry Hospital, says Jason Ashford, JD, chief assistant district attorney for Houston County.

"At this point we know of 10 victims, but there could be more," Ashford says.

The indictment against 30-year-old radiology technician Rachael Michelle Rapraeger was announced at a news conference at the District Attorney's Office at the Houston County Courthouse in Perry. The district attorney said the fake results were entered from Jan. 22, 2009, to April 1, 2010. Ashford says that when radiologists did examine the mammograms, 10 of them actually were positive, and those are the cases in which Rapraeger has been charged. Ashford said that Rapraeger is believed to have acted alone and without the knowledge of any radiologist or other physician.

The computer forgery charges carry a maximum penalty of 15 years each, and the reckless conduct charges carry a maximum of one year each.

"So, we're talking a total of 160 years potentially," Ashford says. Ashford was unable to comment on Rapraeger's alleged motive, because the investigation is ongoing.

"At this point we believe she acted alone; however, we are not just assuming that," he says. "We do not have any indication at this point that she acted in conjunction with anyone else, but we'll see where the investigation goes — and if it leads us to anybody else who was involved."

Victor Moldovan, JD, an Atlanta attorney representing Houston Healthcare, which operates Perry Hospital, issued a statement saying an anomaly in patient records was discovered April 2, and as hospital officials investigated, a technician admitted on April 5 that she signed off on mammograms as if she were the radiologist. The woman, now identified in the indictment as Rapraeger, was sent home that afternoon and dismissed April 6, he said.

The hospital's internal investigation was triggered in part by a quality check, according to Ashley Harris, Moldovan's assistant. The total number of mammograms performed during that time period has not been divulged, she says, so it is not known what percentage of all the mammograms is represented by the number alleged to have been forged.

"The number being focused on is the 1,289 patients impacted by this former employee, and we are communicating with these individuals and their physicians," she says.

The hospital issued a statement confirming the incident but declined further comment.

More problems coming

Part of the problem may be that radiology technicians at most hospitals have a great deal of autonomy, says Susan Friery, JD, MD, an attorney with the law firm of Kreindler & Kreindler in Boston. They work with the patient to obtain the mammogram image and then send the file to a radiology group for review, she says, and those radiologists usually are contracted physicians, rather than hospital employees.

That same employee often does the billing, as well, which creates an opportunity for fraud, because there is little oversight or involvement of others, she says. What she finds curious is that the radiologists apparently never noticed they were making less on mammograms and discovered the fraud that way.

Within the hospital, Friery questions how the fraud could continue for so long without anyone noticing what must have been discrepancies in the documentation. For instance, the radiologist would have to dictate notes and indicate by signing that he or she had read them. Were the documents just not signed, Friery wonders. Or did the tech fake signatures as well?

"The standard of care does not require that the hospital go through every radiology report every month to make sure everything is done correctly," she says. "I will say, however, that the hospital [is] required to be sure that the reports are signed."

Checks and balances needed

It is possible for a radiology tech to skim a few patients at a time, rather than faking results for all mammogram patients, Friery notes. Perhaps the tech wants to lighten the workload a bit or speed up the dispensation of cases at the end of the day, so he or she just fakes the negative result for some portion, according to Friery. That kind of fraud can be avoided by coordinating with the radiology group and requiring accountability, she says.

"There should be a policy that you tell the radiologist how many patients you are seeing that day, and then the radiologist should make sure the numbers match at the end of the day," Friery says. "If they were told 32 patients, and they've only seen 24, they should ask what happened to those other eight patients. There should be a check and balance."

The hospital could be sued for negligent hiring and negligent supervision, Friery says, along with not having the proper protocols and monitoring in place to prevent the fraud or detect it sooner. She expects Perry Hospital to be inundated with malpractice cases as a result of the mammogram fraud, but she says plaintiffs will have to prove that a delayed diagnosis actually caused harm.

"Unless it changed the course of the disease, like showing that you could have had a lumpectomy but now you have to have a mastectomy, the plaintiff won't have much of a case," she says. "An emotional lawsuit based only on the shock of realizing you had cancer for two years but never knew it won't go very far. Some juries will say you were lucky not to have to worry about it for two years."

More cases than reported?

The hospital most likely will claim that the radiology tech was a rogue employee who willfully disobeyed hospital policies and procedures, says Nadeem Bezar, JD, an attorney with the law firm of Kolsby Gordon in Philadelphia. Nonetheless, he thinks Perry Hospital is in deep trouble.

"The exposure for the hospital is tremendous, and it's almost disastrous. We're . . . talking about close to 1,300 mammograms, and that's about 100 mammograms a month or three per day," Bezar says. "There absolutely is groundwork for medical negligence, and it's going to be more than 10 people."

Bezar questions the report that only 10 of the fake negative mammogram results were found to be positive.

"I would suggest that is inaccurate," Bezar says. "The abnormal findings rate for mammograms hovers around 6% to 8%, so we're talking about more like 80 or maybe even 100 abnormal findings should turn up, of which a high number of those could be cancerous lesions. That's it's only 10 is astounding. I'm going to guess that the hospital is underreporting."

The modern way of reading mammograms may increase the hospital's exposure, Bezar says. Rather than the old way of putting a film up on a light box to read, mammograms are now sent digitally to the physician, who can access it only by entering a unique code. That code allows the hospital to track who has viewed the file and when, Bezar says.

The system prevents a tech from entering information in the doctor information areas, so faking a result in the digital system would mean the tech had access to the doctor's identification number. Whether the tech stole it or was given the number would be an important question, he says.

Friery agrees, saying that if a tech obtained that data on a number of radiologists and used them all for fraudulent billing, that is a concerted effort to hide her work. But if she used one doctor's name and identification over and over again, that is another red flag that should have alerted the hospital to trouble.

"I think there's going to be a regulatory problem for the hospital. I'd be asking how a radiology tech could get access to the physician codes, why you didn't have the records cross referenced, why you didn't have checks and balances that discovered this before it went on so long," Bezar says. "Did you have a system that flagged things like a physician signing off on a film when he wasn't even signed into the system? The hospital is going to have to answer some hard questions."


• Susan Friery, JD, MD, Partner, Kreindler & Kreindler, Boston, MA. Telephone: (212) 687-8181. E-Mail: sfriery@kreindler.com.

• Nadeem Bezar, JD, Partner, Kolsby Gordon, Philadelphia, PA. Telephone: (212) 851-9700.