Q&A with Terri Langford: Finding the Medicare Stories Everyone Wants to Read

Terri Langford fought one of the largest government agencies on the planet-the Center for Medicare & Medicaid Services (CMS) – and won big. Her stories in the Houston Chronicle have exposed a huge network of fraudsters in emergency medical transport and millions of taxpayer dollars being paid to dangerous home health care agencies.

As she told me, one of the keys to her great reporting was remembering not to be intimidated by CMS. "They owe you answers like anyone else and they have to prove up their math like anyone else," she said. When the agency refused to talk to her and balked at her public information requests, she just tried harder to get information elsewhere.

"I had to shake bushes extra hard for industry sources because no one really liked or wanted to talk to me about this," she told me. "The rest was just driving around a lot. So much driving." Until she finally parked and published a series that already has prompted federal legislation and appears to have spurred a few federal prosecutions as well.

Langford answered questions from me via email. The first part of our conversation appeared on Wednesday. The second part is below. It has been edited for space and clarity.

Q: What was the initial reaction from readers about your private ambulance piece, and what was the reaction in the health care community?

A: I've been a reporter for 26 years at three papers and a wire service. Nothing I have ever done prepared me for the overwhelming reader and health care community response. It hit a raw nerve. Remember, we are home to a huge health care community and an enormous population overall. Houston is the nation's fourth largest city.

If you explain to readers where their money is going – what's really been missing from a lot of the Washington coverage of CMS – they'll read every word you write and beg you to write more. Not a week has gone by where I don't hear from someone with a tip or a suggestion. I have enough story ideas generated from these stories – and they're not all Medicare related – to take me through all of next year. It's been amazing. But these stories gave me even more credibility with law enforcement officials, who are now more willing to talk to me about this problem. They've been frustrated by health care fraud for years here.

The day after the first story appeared, I got a call from our security guard in the lobby. The Harris County District Attorney had someone from her office deliver a three-inch stack of documents that detailed her office's two-year frustration with Washington to do something about the ambulance fraud here. I had no idea until after we published that this was such an issue with her. I had mistakenly believed it was only frustrating for federal health care investigators here in Houston and that her office had no jurisdiction because I didn't find a lot of local court cases involving EMS companies at the Harris County District Clerk's office. This is what I mean about how your theories and assumptions can be wrong. When they are wrong, learn from it. I did. 

Q: There have been a number of criminal probes, indictments and jail sentences following your series. Some of those cases seem to have been in motion while you were reporting. Are there specific results that you think were prompted by your work?

A: I'd like to take credit, but I believe those prosecutions were in motion before my stories ran. My timing was great. I started to notice something that was just beginning to come to a head with CMS and that no one had written about. That said, after I made my first FOIA requests in April 2010 regarding mental health clinics a CMS program integrity worker in Dallas informed me that she had forwarded my FOIA requests to HHS OIG investigators.

I was furious and informed her that wasn't the point of FOIA, to be their informant. Nothing I could do about it. But I assumed everything I asked for, from that day forward, was being CC'ed to HHS OIG. So who's to say? A federal prosecutor told me after we published that he had learned "so much" from them and that he "didn't really understand how some of it was connected" until he read what I wrote. 

Interestingly enough, the subsequent arrests, including one I wrote about this week, continue to prove up our findings. Many EMS companies in the Houston area are operating a human trafficking operation, plucking mentally ill individuals who have Medicare coverage from personal care homes and transporting them in droves to mental health clinics, who can also bill Medicare.

Q: Then you turned your attention to home health firms, which led to a story in early December about all the money being made of Medicare in that industry. What prompted that piece?

A: While waiting for FOIAs from CMS, I filed some requests for home health care payment totals for Texas. This is the one of the greatest areas of fraud, according to federal investigators here. I got the data in June (free) but was so busy with EMS that I had to sit on it until after the EMS/clinic stories.

Q: With the home health care firms, you had a different framing. Here you weren't accusing anyone of outright fraud. Instead, you were saying that all the firms had broken the rules at some point but yet were still receiving funds. What made you decide that there was a story here and not just the typical case of regulators finding problems and the businesses being regulated making fixes along the way?

A: First, it's a lot of money. It dwarfs the money paid to private EMS and clinics. I decided to take a different tactic, by looking online at inspections of home health companies. I'm used to looking at assisted living, nursing home and day care inspection reports where most are dinged for more minor things like not having a fire extinguisher or no smoke alarms. Important stuff, sure. But not like what I saw when I looked at home health reports where agencies were cited for failing to conform to any Medicare standards.

I'm also fascinated with CMS' reliance on the state to tell them which ones violate federal rules. I was trying to move the conversation to how CMS relies on states as a safety contractor and yet appears not to stop the money despite the findings.

Q: How did you find out that Rep. Kevin Brady was going to ask for an investigation based on your work?

A: I knew nothing about it until Rep. Kevin Brady emailed me last week that he was going to do this. I was completely surprised.

Q: Republican senators and congressional representatives have made a cause out of Medicare fraud in part because many of them would like to see federal programs eliminated. Health care funding has become a hugely contentious issue over the past three years. While you were reporting, did the thought that these stories might become political talking points cross your mind?

A: Not really. I was sure some might notice, but I assume they pay more attention to Washington media than caring about some reporter from Houston. The entire time I was reporting, I was focused on using this small area of Medicare spending to explain some of the larger fraud problems and how Houston fit in that larger fraud picture. And I had an editor who was totally engaged in this project who saw the bigger picture and just pressed me to write it well so people would actually care about it. I thought it was fascinating.

But I was worried that was because I'm a government nerd. I focused on the money trails and the connections with clinics. That's what I went after. This horrible human trafficking scheme that taxpayers pay for. Look, I'm a C-student from State U. I'm not a data Jedi knight. But this stuff is not hard. And if I can find something so compelling about Medicare and explain it, any reporter can. Break it down in pieces, write it like a suspense narrative, take the readers with you in it and you'll be amazed at the reaction.

Writing about Medicare, figuring out how the people and systems behind the fraud finally marries my two favorite subjects: big crime and complex, twisted government systems. These are the best stories anyone reporter can cover today.  But if you had told my 25-year-old self that I would one day be thrilled to write about Medicare, I would have just laughed.

Q: Forgive me if this sounds like a job interview question, but in looking back on all the work you've done this past year, what have been the two or three biggest challenges and how did you overcome them?

A: The number one challenge was breaking through the whole arrogant "You're not with the New York Times/Wall Street Journal/Washington Post/CNN/Politico/60 Minutes" bias that is inbred at federal agencies. I believe that CMS officials stalled on answers and at first incompletely filled my FOIA requests because they thought I'd just move along and drop the story when they wouldn't answer me.

I'm used to that kind of attitude from some federal agencies. But CMS seemed to take it to a whole different Gaslight level. "What exactly do you mean by problems with private EMS companies in Houston" a press officer asked, as if I were speaking Italian. They're not used to having to prove up their math to news organizations outside the Beltway.  They're not used to having to explain themselves to reporters at smaller news organizations, even if by smaller it's the largest newspaper in Texas.

They actually made me file a written request just to get their current annual budget number, something that is vastly different in different stories based on different criteria. But when they wouldn't talk to me or dodged my emails, I just dove into their contractors' websites, got on all the contractor newsletter mailing lists, amped up my Google Alerts and pulled every GAO, HHS OIG audit I could. I traced Medicare fines against clinics through the rather obscure federal Administrative Court system.

I even sat on a CMS conference call with EMS providers, which was a real eye-opener. Imagine frustrated EMS providers trying to do the right thing and get some clarity from a $760 billion agency and being told by CMS that "Um, you need to call the billing contractor about that." What?

To this day, CMS has refused to say on the record that there is an overbilling and overpayment problem with Texas EMS providers and mental health clinics. But they didn't have to. The data did and so did the memos and alerts their contractors posted on their own website. And eventually, the story came together. A second problem was there was just so much information for one reporter to sift through. This was a Russian nesting doll of a story. As soon as I tracked down one thing, five more leads popped up. They continue to do so.

Q: How did you handle all of those leads?

A: From the start, I had an incredible editor, Jacquee Petchel, who had once covered social services for the Miami Herald. Together we have a vast knowledge of social service systems. She immediately saw the big picture and was totally engaged in this story.  She frequently pulled me out of bouts of pessimism because there was so much I wanted to be able show but couldn't because of incomplete data and/or generally a lack of bodies in today's newsrooms. She made me focus on what I could find and quit wasting time on what we couldn't.

The data didn't tell us which EMS companies were engaged in fraudulent Medicare billing. I wish I could have proven that. Also, there are far too many companies here and I didn't have enough data to prove how they close, change addresses and rename but are associated with the same owners. But the sheer dollar numbers and number of companies here proved to us that something was out of kilter and that was a heck of a story by itself.

My editor also went with me to look at what I had found, which was awesome. Her help in keeping me focused when we had a million threads and a pile of information all left for one reporter to sift through really helped land this thing. Like a lot of reporters, I can report up to deadline and beyond. There comes a time where you just have to say stop. I have a hard time with that. Jacquee does not.  The other thing I worried about constantly was that the editors here at the Chronicle would get itchy that I wasn't in the paper as much. That was nerve-wracking.

But I had tremendous support from the start, both from my editors and from the Hearst Corporation. I don't think I could have done this story anywhere else but at the Houston Chronicle and at Hearst.

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Photo credit: sabertasche2 via Flickr