Q&A with Terri Langford: Driving the Medicare Money Trail

Terri Langford reports like a good cop. An investigative reporter on the Houston Chronicle's Enterprise and Projects Team, Langford walks her beat, gets to know the community she's covering, spends a lot of face-to-face time. In her investigative series on how Medicare providers are gaming the system, she shows readers how she documented some facts with records and data and how she documented others just by being there.

Langford told me that she has done very little health reporting and had to do a lot of homework for the series. She moved to the Chronicle in 2004 from The Dallas Morning News, where she reported on child deaths, transportation safety and airport security. Langford also worked for the Associated Press, both in Houston and Dallas. I interviewed her via email, and our conversation has been edited for length and clarity. The first part appears below. The second part will appear on Friday.

Q: When did this trail first started for you and what prompted the line of inquiry that led to your series?

A: In some ways, it started in 2005. Back then, I wrote about a clinic that was renting space to an adult day care company. A driver for that company was involved in a crash that killed all five passengers, all patients from the adult day care. In June 2010, the Texas Tribune's Emily Ramshaw and I published a collaborative project on abuse within residential treatment centers for children. Just a few days later, a woman who lived in the same neighborhood as that clinic from 2005 contacted me. She remembered my story. "You need to come back up and check out private ambulance traffic up here," she said. "It's unbelievable."

Q: There have been many investigations about Medicare fraud in the past. Were there any stories in particular that you read for ideas and inspiration?

A: I'm sort of a Jane-of-all-beats. I've written about everything from accident investigations to the seizure of polygamist children. There's little in the state and federal courthouses that I haven't covered. But I'm happiest reporting on big crime and twisted government systems. While I'm tasked to cover social service stories, I don't consider myself a health care reporter or a social services reporter. I couldn't tell you the first thing about good drug trial practices and I know next to nothing about hospital regulations.

Until I began delving into the ambulance business, I was a Medicare rookie. I knew it was the nation's largest insurer for the elderly, and I knew the difference between it and Medicaid. That was it. But I am an open records junkie, and about the time I started on this I was loving the work that David Donald of The Center for Public Integrity and Maurice Tamman of the Wall Street Journal were doing. Both have been fighting the Center for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) for better records transparency when it comes to Medicare claims data.

I'm also a huge fan of my former Dallas Morning News colleague, Charlie Ornstein, and his work both for the Los Angeles Times and ProPublica. I just can't say enough about the good work ProPublica has done on health care. In Texas, I always have my eye on the terrific social services/health care coverage of Bob Garrett at The Dallas Morning News and Emily Ramshaw who at Texas Tribune. I hate getting beat by them.

Q: Because there have been so many Medicare investigations, did you or your editors worry that you had to have something new to say? What kind of bar did you set for yourself?

A: I am bored to tears by Medicare process and policy stories and so is my terrific editor, Jacquee Petchel. She wages a daily war on boring stories. After all the reporting was done, she emphasized that it had to be written in a compelling way or no one would care. We didn't want some treatise on how Medicare works. It helped that this didn't start out as a "Medicare story." It started out as a mystery story, a "why does Houston have so many private ambulances?" story.

A look at the Texas health department's licensure data for EMS companies showed Houston and the surrounding suburbs were an EMS mecca and it wasn't because Houston is the largest city in Texas. Dallas had fewer than 20 at the time. Austin had fewer than five and Houston had more than 300. We talked about just doing the story as a quick weekender. But, after my visits to clinics and after following these ambulances and seeing able bodied patients walk up and get into them, Jacquee said to keep digging. We were both convinced there was a much better story to be had.

Q: How did you decide where to look for records and what was the first records request you made?

A: When I work on an unfamiliar topic, I always do a quick Google/Nexis search for past stories on the topic and make a run at the IRE tip sheet library. But this time, there was absolutely nothing. No stories on how private EMS companies operated and precious little about their regulation. Then I hit the U.S. Government Accountability Office and the Office of Inspector General for the U.S. Department of Health & Human Services. I pulled some audits there, but those only told about past screw-ups based on a sample of records in a handful of states. I made Google Alerts do some checking for me by putting in the keywords such as "ambulance" and "Houston" and "Medicare" to see what exactly was being written now about ambulances.

The only thing I really found – which is still a great undone national story – is how Medicare's recent reduction of emergency ambulance rates is putting a chokehold on municipal 911 EMS (i.e. local fire department) budgets. The first thing I received was the Texas health department's EMS licensure database in Excel, which is easy to find online. You also can get the state health department to pull it for you. Free. Then knowing more about Medicaid, which is distributed for HHS by the Texas Health and Human Services Commission, I went to the state agency and asked them for a six-year total of Medicaid claims and payments to Texas EMS companies, including the companies' addresses. That, too, was free. I went to the state first, because their turnaround time is quick and I wanted a template for what types of payment data are available on the Medicaid side, which is good ammo to have when you go to the feds and they try to tell you that such things are not available on the Medicare side. In fact, I ended up sending the state's Medicaid EMS spreadsheet to CMS. When the feds acted confused about my very simple request and said: I want it like this.

Q: The first piece you wrote in October focused on private ambulances. Reporters often assume that private companies that aren't publicly traded won't have a paper trail. How did you find a way in?

A: Despite what little I know about medical reporting, here's the one thing I know about health care-related businesses from my social services experience. They rarely pass up an opportunity to access taxpayer funds and they're regulated in some way. Find the taxpayer funding and the regulator and you're half-way home. For me, that was Medicare, the state and city health departments. I pulled city EMS violations and their own permit databases. But even more important is understanding how businesses are created in your city. I background a lot of businesses and people every day. I'm a frequent user of the online Harris County Clerk's Office Assumed Names database (free), Nexis (fee-based) and the Texas Secretary of State's Office (fee-based), which is where you go if you incorporate your business. Also, the Texas Department of State Health Services (DSHS) has a public license database online (free).

There you can check the address, license status, administrator's name and medical director name, as well, as a list of all EMTs and paramedics who say they work at that company. Also, look at how businesses are clustered. Look at common factors. Look for unexpected players. For me, those were the medical doctors who are hired as "medical directors" for these companies. Doctors have state licenses available online and became another way to check the companies' health. The most interesting about all of these records was the EMS company addresses. You will notice fairly quickly that Houston area EMS companies were mostly headquartered on the city's southwest side. That's where most of the city's Medicare recipients and low-income residents live. Any reporter interested in covering your city's poorer residents needs to ask the U.S. Social Security Administration for payment data by zip code. I got it free. I have it on my desktop and use it all the time to vet theories I have about neighborhoods. That and my Medicare enrollee totals by zip code are my own sort of home-made poverty/disability index.

Q: Let's talk about Daniel McCall. You describe him as having no idea why he made an ambulance ride to a therapy center, but he does have a caretaker and does seem to be confused about a lot of things. What made you think that he was a credible source to show that these ambulance rides were unnecessary?

A: Any mentally disabled individual has the right to tell – or not tell – his or her story. Daniel did not know exactly who called the ambulance, but he believed it was his caretaker. He knew the correct name of his caretaker. He provided – as did one of his roommates and a home health care worker - great detail about his living arrangements. I found him incredibly lucid. I've covered the mentally disabled throughout my career. Interviewing them is tricky because they may not have all the details in a neat linear fashion. But they have information that you can go verify with those who do. And I did. Ultimately, his caretaker conceded that Daniel had taken an ambulance when he didn't really need to.

Q: One frustration you must have had was spending all this time tracking these apparently bogus ambulance rides only to be unable to find the hard document proof that they were phony. As you say in your story, "Privacy laws prevent the Chronicle from obtaining specific data about McCall's journey." What avenues did you try to verify his story and to find out whether Medicare had been billed?

A: I saw Daniel get in the ambulance at the clinic, and I followed him to his home, an apartment on Houston's northwest side. I asked the EMS drivers about the transport. They refused to talk, gave me the name of the owner and left. I talked to Daniel who said he had just been dropped off by ambulance from the clinic where I saw him board. He said ambulances came every day to pick him up. I called the owner, who said her records did not show him. I asked CMS for trip data, which is known as origin/destination data. CMS will redact or omit individual residential addresses but will show clinic addresses.

The EMS company I saw picking Daniel up had two trips from Daniel's clinic on that day. We reported what we saw and what people said about the trip. I had the name of Daniel's caretaker who has been crossways with state regulators for years. At first she said she never had used private ambulances. When pressed, she admitted she had for herself, for a sister, and for others, including Daniel. We reported all of this.

Q: One of your most stunning findings was about what Medicare doesn't know. You wrote, "After a request by the Chronicle to view those records - essentially a prescription to ride at taxpayer's expense - Medicare officials conceded they are never submitted to the federal agency." What sort of effort did it take on your part to get them to admit that?

A: That's a funny story. Both my editor and I were obsessed with this issue. It nagged at me for months as CMS officials continued to refuse to talk to me on the record. I knew Medicare requires enrollees to get a Physician Certification Statement that declares a Medicare patient in need of an ambulance. But I couldn't find anyone who could tell me whether CMS' billing contractor, which in this case is TrailBlazer Health Enterprises, ever sees these forms. In other words, if Medicare requires you to get a doctor to fill out the form to get an ambulance ride, where does the form actually go?

I knew that EMS companies had these forms as part of their records, but the few EMS companies who would return my calls said they didn't have to send in the forms to get paid. I was floored. This one form, if collected by billing contractors, might be a simple way to prevent fraud. I scoured CMS' dense website and their contractor websites looking for anything that said anything about the certification forms making their way to Medicare's bill collectors.

At the same time, I getting so many letters from CMS about my FOIAs - "Ms. Langford, This letter is in response to your Freedom of Information Act (FOIA) request to the Centers for Medicare and Medicaid Services (CMS) dated " - that I wasn't reading them very well. I threw them in a folder on my desktop and moved to the next thing. Then one day, I sat and read them carefully, and I was stunned. That admission came in a typical "Ms. Langford" letter, written on Feb. 16, 2011, about some data I wanted to use to test some theories I had about clinic connections. That was a gift.

Q: When did you decide to start talking to these ambulance agencies and clinics? It seems the clinics were more cooperative. Why is that?

A: I really wanted to see what the Medicare payment data looked like before confronting people. I always assume my information or assumptions could be wrong. That's why I love data. In the meantime, I followed EMS companies and noted where they were coming from, where they were going. I watched mentally ill people wait for their ambulance rides. The clinics really couldn't dodge me because they're in a standing office that is open with a sign out front and customers coming in.

EMS companies, on the other hand, were harder to find. Maybe an address for a company would end up being an empty office or a home. If I reached someone by phone, they would tell me they'd call back and then didn't. Or they would tell me they couldn't talk because they're worried the bad actors in the industry would abscond with their clients or sabotage their businesses in other ways.

That's not to say those in the EMS industry didn't talk. I had a handful of spirit guides who did not want to be quoted but helped me frame my requests, explained how the Medicare billing process worked, and vented their frustrations with me about what was going on in Houston. Word got out quickly throughout the industry's better players about what I was attempting to do. And a few of those people called me directly and opened often with "What do you want to know?" That was an amazing experience.

Next: How readers and regulators reacted to Medicare's ugly side

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