Dr. Annie Bukacek of Hosanna Health Care in Kalispell was surprised when a 30- to 40-foot-long command-post vehicle pulled up unannounced last week, along with a posse of state and federal health-care fraud investigators.

That marked the latest in a string of inquiries that started last April. Apparently someone alleged abuse of patients or fraud with regard to Medicaid billing involving Bukacek's medical practice. Questions about praying with patients also have been raised.

Bukacek said she spent an hour and a half Wednesday with an FBI agent, a criminal investigator and two health-care fraud investigators, trying to get some answers about why her small practice was under scrutiny.

"They said they have to follow up every allegation made," Bukacek said. "I believe these individuals are people doing their job. I find no fault in them. But think about the federal capacity for harassment. Will I continue to get an average of one government investigation a month?"

Bukacek, an outspoken critic of President Obama's health-care reforms and president of Montana ProLife Coalition, said the visit last week was the fourth or fifth investigation since last spring. She was astonished at the tax dollars invested and the intrusion into patient privacy as volumes of records were copied and carted away.

It was done legally under health-care subpoenas obtained apparently by Assistant U.S. Attorney Jessica Fehr with the U.S. Department of Justice in Billings.

"This is highly personal information," Bukacek said. "They have access to everything."

When contacted in Billings, Fehr would not comment. She said the policy of her office is "to neither confirm nor deny the existence of any investigations."

The policy is designed to protect the reputations of physicians if allegations prove to be unfounded. Attempts to contact investigators were unsuccessful.

Bukacek said she decided to go public for several reasons. The first was that she wanted other physicians under investigation to know they are not alone.

"I have a very strong constitution and can see the humor of these types of situations," she said. "For some physicians, this kind of thing would be devastating."

She said her primary concern was for her patients. Bukacek said the investigators had access to patients' marital history, children's history, drug addictions, sexual orientations, religious preference, medications and illnesses.

"These investigations are a huge infringement on patients' rights to privacy," she said.

Bukacek said many people have suggested she has been targeted because she is an outspoken president of Montana ProLife Coalition and is on the steering committee of the Coalition Protecting Patient Rights.

"I have been traveling throughout the state speaking as an individual against Obamacare," she said.

She said she finds this difficult to believe because she doesn't consider herself that influential, but the timing seems at least suspect.

Bukacek said the cost of these investigations has most likely outstripped the amount her office has billed Medicaid in a little over six years of operating the clinic. She said the recreation-vehicle unit that parked outside her door must have cost hundreds of thousands of dollars.

"This is your tax dollars at work," she said.

Two of the fraud investigators told her that the return on fraud cases was greater than the cost. But she can't see how that would pencil out in a case like hers.

Bukacek points out that primary care physicians represent the lowest rung of physician income.

"Because we, at Hosanna Health Care, allot 30-, 45- and 60-minute slots for patients, we're at an even lower rung regarding income," she said.

Because of the thousands of pages of rules and regulations, Bukacek said any physician might unknowingly fail to comply with one. She recently learned about a "red flag rule" applied to physicians that has to do with protecting patient identities with penalties of $2,500 for noncompliance.

"This is a way the federal government can crush anyone financially that they choose," she said.

Bukacek said she can't afford to hire a lawyer to protect her against these unknown allegations. She received a letter that just said the unit investigating her is part of the Montana Division of Criminal Investigation that looks into allegations of Medicaid fraud and patient abuse.

"So the insinuation is that there have been allegations of fraud against me," she said. "This is embarrassing to me because people have a tendency to judge guilty until proven innocent."

Bukacek points out that anyone - a disgruntled ex-employee or patient or someone who doesn't like a physician's looks or politics - could trigger an investigation and cost a physician as well as the government thousands of dollars.

While at Hosanna Health Care, investigators questioned staffers and looked at schedules and files, apparently trying to determine if she actually spent the time with patients reflected in her billings. They asked for a list of all her former employees.

Bukacek finds it ironic that spending more time with patients than most physicians has attracted a fraud investigation. In a letter she wrote to Fehr, she pointed out that the higher rate billed for a longer visit doesn't pay as much as billing for four patients in one hour.

"We have chosen to do it this way because we are absolutely convinced that superior quality patient care requires time," Bukacek said in the letter.

She said she first became aware of the investigations in late April or the beginning of May when three or four of her patients called her.

"They had been contacted by Medicaid, asking them questions about me - how much time I spent praying with them, how often I see them, what they think of me," Bukacek said. "We called the Medicaid office to find out what this was about and got no answer."

She said that the investigators indicated that, along with medical billing, her praying with patients was part of their reason for looking into her clinic. They had many questions.

"How much time we spend on it, how we decide how to pray, how we pray with non-Christians."

A deeply religious person as reflected by the name of her clinic, Bukacek said she obtains patients' permission before praying and respects their wishes if they decline. She estimates that a typical prayer consumes maybe 30 seconds during a visit.

Following the calls to patients about prayer, Bukacek said she received a subpoena in June from Medicaid Criminal Investigative Services for patient charts. She sent the information but heard nothing.

Another subpoena arrived in July or August. Because of the time frame, she suspects a disgruntled employee may have something to do with the latest investigation.

Bukacek said it could be that she is part of "a ramped up" investigation emphasis with the discussion of Medicare and Medicaid fraud related to health-care reform efforts.

"I think the intention is good," she said. "The people were very nice."

Bukacek just can't understand why her small office with such little prospect for significant recovery was investigated as compared to the huge medical establishments paid millions of dollars from Medicare and Medicaid.

"We're so unimportant in the scheme of things," she said. "It's amazing to me."

She also pointed out the potential chilling effect this may have on others accepting Medicare and Medicaid patients with reimbursements below the cost of providing service, slow payment and heavy paperwork.

Quite a few physicians and many local dentists now refuse to accept Medicaid patients due to low payments, she said.

"I'm telling you, physicians will no longer be willing to see those patients that need us most," Bukacek said.

Reporter Candace Chase may be reached at 758-4436 or by e-mail at cchase@dailyinterlake.com.