Date Posted: Wednesday, February 21, 2024

 

The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

 

Florida Research Hospital Agrees to Pay More Than $19.5 Million to Resolve Liability Relating to Self-Disclosure of Improper Billing for Clinical Trial Costs

 

Early January saw a case involving a non-profit cancer treatment and research center based in Tampa, Florida, agreeing to pay $19,564,743 to resolve its civil liability under the False Claims Act for improper claims submitted to federal healthcare programs for certain patient care items and services provided during research studies that were not eligible for reimbursement.

 

This settlement resolves the research hospital's civil liability for claims that it submitted to Medicare and other federal healthcare programs during the period from 2014 to 2020 for services that were not reimbursable under Centers for Medicare and Medicaid Services rules governing reimbursement for clinical care provided in connection with clinical research trials. Specifically, it billed federal healthcare programs for items and services provided as part of clinical trial research that should have been billed to non-government trial sponsors.

 

The federal share of the settlement is approximately $18.2 million, and the state Medicaid share of the settlement is approximately $1.3 million.

 

In connection with the settlement, the United States acknowledged that the research hospital took several significant steps entitling it to credit for cooperating with the government. After learning of these issues, the research hospital initiated an independent investigation and compliance review and voluntarily provided the government with a written disclosure of its findings. It cooperated fully with the government's investigation of the conduct and implemented prompt and substantial remedial measures.

 

"Protecting the nation's healthcare programs is a top priority of our office," said a U.S. Attorney on the case. He continued, "When those who receive funds from government healthcare programs discover that they have submitted improper claims, we encourage them to promptly disclose the issues and cooperate fully with investigators to reach an appropriate and swift settlement. That's what [this research hospital] did here: self-reported its improper claims, cooperated with government investigators, and took action to remediate its billing systems."

 

The claims resolved by the settlement are allegations only and there has been no determination of liability.

 

Source: Florida Research Hospital Agrees to Pay More Than $19.5 Million to Resolve Liability Relating to Self-Disclosure of Improper Billing for Clinical Trial Costs . (2024, January 4). www.justice.gov.

 

Hospitals Pay $7.25 Million to Settle Allegations That They Violated the False Claims Act

 

Tennessee hospital systems have paid $7,250,000 dollars to resolve allegations that they violated the False Claims Act. This settlement resolves allegations that they caused the submission of false claims to Medicare that resulted from improper financial arrangements between the hospitals and another clinic, including kickbacks that they paid to the clinic as part of its affiliation with the clinic.

 

"Federal law prohibits money from influencing where a doctor refers a patient for treatment to keep doctors focused solely on what is best for the patient," said a United States Attorney on the case. He continued, "We contend that [these hospitals'] affiliation with the [clinic] ran afoul of that law. When hospitals pay kickbacks to physician practices, regardless of what form those kickbacks take, they can expect to be the focus of our enforcement efforts."

 

In its complaint, the United States alleged that, from December 2011 until February 2019, the hospitals had a multi-agreement affiliation with the clinic and a university health science center. The affiliation agreements with the clinic included an Asset Purchase Agreement, Management Services Agreement, Leased Employee and Administrative Services Agreement, and Professional Services Agreement. According to the complaint, the hospitals used these agreements as a vehicle to pay kickbacks to the clinic in part to induce the clinic to refer Medicare beneficiaries to the hospitals. The affiliation ended in 2019 and is no longer ongoing.

 

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by two gentlemen, one, a former president of one of the hospitals, and the second, a former Dean of the University Health Science Center. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The Act also permits the United States to intervene and take over the litigation and receive a portion of any recovery, such as the United States did here. The gentlemen here will each receive a share of the recovery.

 

The claims settled by the settlement are allegations only, and there has been no determination of liability.

 

Source: Memphis-Based Methodist Le Bonheur Healthcare and Methodist Healthcare-Memphis Hospitals Pay $7.25 Million to Settle Allegations that They Violated the False Claims Act . (2024, January 4). www.justice.gov.

 

New York Hospital Pays Over $800,000 to Settle Claims That Physician Practices Improperly Billed Government Healthcare Programs

 

A New York hospital has agreed to pay $801,000 to resolve claims that two radiology practices improperly billed Medicare, Medicaid, and TRICARE for images used in image guided radiation therapy treatments (IGRT) provided to cancer patients.

 

The settlement agreement, which resolved claims under the Federal False Claims Act, was approved on January 19, 2024.

 

A United States attorney on the case stated, "The defendants provided substandard care to cancer patients by not properly or timely reviewing medical imaging and then billed taxpayer funded healthcare programs for these shoddy services." He continued, "My Office is committed to holding healthcare providers accountable for such conduct."

The two clinics, which are no longer operating, provided outpatient radiation oncology services to several Brooklyn communities. IGRT is a type of cancer treatment that uses imaging technologies such as PET, MRI, and CT scans to deliver radiation more accurately and safely to cancer cells. It uses periodically taken images to guide the precise delivery of radiation.

 

The United States claimed that between 2012 and 2018, the two clinics billed for images utilized in IGRT when such images were either not reviewed, or were not timely reviewed, and therefore were not reasonable and necessary.

 

Further, the investigation found that initial consultation sessions at one clinic were in some instances billed at a higher coding level than appropriate.

 

Under the terms of the agreement with the United States and the State of New York, the hospital will pay a total of $801,000, with $694,999.71 going to the United States and $106,000.29 to the State of New York. These funds will go to the Medicare, Medicaid, and TRICARE programs.

 

The settlement includes the resolution of a civil action brought under the qui tam or whistleblower provisions of the False Claims Act. Under the qui tam provisions of the False Claims Act, a private party can file an action on behalf of the United States and receive a portion of the settlement if the government takes over the case and reaches a monetary agreement with the defendant.

 

The claims resolved by the settlement are allegations only and there has been no admission of or determination of liability.

 

Source: New York Presbyterian Hospital Pays Over $800,000 to Settle Claims That Physician Practices Improperly Billed Government Health Care Programs . (2024, January 25). www.justice.gov.

 

United States and State of Washington File False Claims Act Complaint Against Health System for Knowingly Endangering Patients and Fraudulently Billing for Spinal Surgery Procedures

 

Late January saw a complaint filed, alleging that a Washington state health system knowingly endangered patient safety and falsely and fraudulently billed Medicare, Medicaid, and other federal healthcare programs for spinal surgery procedures performed at one of its hospitals between 2019 and 2021 by a former neurosurgeon.

Between 2013 and 2019, the neurosurgeon practiced at another hospital system amidst allegations that he was performing medically unnecessary surgeries, harming patients, and falsifying diagnoses. This hospital permitted the neurosurgeon to resign.

 

The Complaint alleges that following the earlier resignation, this hospital system hired the neurosurgeon to perform neurosurgery services at one of its hospital locations. The Complaint alleges that during the hiring process, the hospital system became aware of concerns and "red flags" about the neurosurgeon and his surgical judgment from his time at the previous entity, but, recognizing that he was a "workhorse," made the decision to hire him and allow him to begin seeing patients and performing surgery at this hospital in July 2019.

 

The Complaint further alleges that in October 2019, this hospital system recognized that he was performing a high volume of surgeries and generating significant revenue for the organization, and so placed him on an incentive compensation structure, meaning that the greater volume and complexity of surgeries performed by the neurosurgeon, the more money he would make.

 

The Complaint also alleges that in February 2020, the United States Attorney's Office specifically informed this hospital system that it was investigating concerns that the neurosurgeon was harming patients, falsifying diagnoses, and performing medically unnecessary surgeries.

 

According to the Complaint, despite receiving this information, as well as multiple internal complaints and concerns that he was performing medically unnecessary surgeries and endangering patients, the hospital system made the decision to allow him to continue seeing patients and performing surgery until the Washington Department of Health summarily suspended the neurosurgeon's ability to perform surgery in March 2021.

 

The Complaint alleges that the hospital system not only endangered patients through its conduct, but falsely and fraudulently claimed and received reimbursement for millions of dollars from federal healthcare programs between July 2019 and March 2021.

 

The federal healthcare programs are: (1) Medicare, which provides health coverage to elderly and disabled Americans; (2) Washington State Medicaid, which is jointly administered and funded by the United States and the State of Washington, and which provides health coverage to low-income Washingtonians; (3) the U.S. Department of Veterans Affairs (VA) Community Care program, which provides health insurance coverage for veterans for certain specialized services that cannot be performed at VA facilities; (4) the TRICARE program, which provides health insurance coverage for active duty and retired military service members, reserves, and their families; and (5) the Federal Employee Health Benefits program, which provides health insurance coverage to federal civilian employees.

 

In April 2022, the first hospital involved (the one in which they told the neurosurgeon to resign) agreed to pay approximately $22.7 million and implement a standard of care corporate integrity agreement to resolve its liability concerning surgical procedures performed by the neurosurgeon and another that billed to federal healthcare programs.

In April 2023, he agreed to pay approximately $1.2 million to resolve his individual liability under the False Claims Act.

 

According to court documents, while the United States' and State of Washington's investigation of the first organization began in February 2020, in April 2022, a former patient of the neurosurgeon at this hospital system filed a qui tam complaint under seal in the U.S. District Court for the Eastern District of Washington.

 

When a whistleblower, or "relator," files a qui tam complaint, the False Claims Act requires the United States to investigate the allegations and elect whether to intervene and take over the action or to decline to intervene and allow the relator to go forward with the litigation on behalf of the United States. The relator is generally able to then share in any recovery.

 

Over the past decade, recoveries in the Eastern District of Washington in False Claims Act cases have exceeded $400 million.

 

Source: United States and State of Washington File False Claims Act Complaint Against MultiCare for Knowingly Endangering Patients and Fraudulently Billing for Spinal Surgery Procedures . (2024, January 26). www.justice.gov.

 

Texas Clinic Owners Agree to Settle Allegations Regarding Acupuncture Devices

 

The owners of this Texas clinic have agreed to pay a total of up to $108,000 to settle allegations they submitted false claims.

 

From January 27, 2016, to September 16, 2020, a chiropractor and two nurse practitioners at this Texas clinic billed Medicare for the surgical implantation of neurostimulator electrodes. These are invasive procedures usually requiring the use of an operating room. Medicare pays thousands of dollars per procedure. However, the government alleged that no surgery was involved. Instead, patients received devices used for electro-acupuncture, which only involves inserting needles into patients' ears and taping the neurostimulator behind the ears with an adhesive.

 

In addition to the financial settlement, this Texas clinic agreed to a five-year period of exclusion from participation in any federal healthcare programs.

 

To date, this is the 11th case the Southern District of Texas has resolved for similar conduct.

 

Source: Richmond Clinic Owners Agree to Settle Allegations Regarding Acupuncture Devices . (2024, January 16). www.justice.gov.

 

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC.

 

Sonal has over 13 years of experience understanding the art of business medicine. She is a nationally recognized thought-leader, speaker, author, creator, and consultant. As the CEO & Principal Strategist of SP Collaborative, LLC, she serves as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical coders, auditors and compliance professionals in working together to elevate coding compliance education for the business of medicine.

 

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