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November 9, 2015 Healthcare Fraud

Justice Department Settles With Hundreds of Hospitals Amid Healthcare Fraud Claims

hospital hallway lined with empty chairs

In today’s case, we review one of the largest False Claims Act settlements in terms of sheer breadth, number of defendants, and number of healthcare fraud claims. The settlement, which involved 457 hospitals and healthcare facilities across the United States, resulted in a $250 million payout to the government, and sent an unequivocal message to the rest of the medical community – follow the guidelines or face certain liability.

The lawsuit involved thousands of allegations of wrongful implantation of cardiac defibrillators, devices designed to monitor heart rhythms and implement an electric shock if necessary. According to the whistleblower, heart surgeons across the nation implanted these devices too soon after major cardiac surgery, thereby triggering the False Claims Act when billing for the procedures in violation of Medicare and Medicaid rules.[1.Cohn, Meredith. “Justice Department settles with hundreds of hospitals, 10 in Maryland, over defibrillators.” The Baltimore Sun. (Retrieved Nov. 4, 2015).]

The case was filed seven years ago by two whistleblowers: a cardiac nurse and a Medicare compliance officer. The pair is expected to split close to $38 million under the False Claims Act’s qui tam provisions. 

Details of the allegations

The details of the allegations involve the implantable cardiac defibrillators centers on the timing of the implantation. The cost of the procedure to implant the devices was only reimbursable if implanted within a certain number of days following major surgery, such as bypass surgery or angioplasty. A surgeon can seek reimbursement for the procedure no earlier than 40 days following a massive heart attack and no sooner than 90 days following invasive heart bypass surgery.

This policy gives patients time to heal, which would possibly negate the need for the implantation all together. According to the complaints, doctors routinely implanted these devices either during treatment for the triggering event or shortly thereafter – in blatant violation of Medicare and Medicaid rules.

Opponents of the regulations asserted that it does not always make sense to wait so long to implant the device and that certain patients need continuous cardiovascular monitoring as soon as possible following surgery. Doctors also lament that patients are forced to endure two separate procedures when the same result could be achieved with one.

Nonetheless, the government settled with 70 health systems in 43 states, and stated “[W]hile recognizing and respecting physician judgment, the department will hold accountable hospitals and health systems for procedures performed by physicians at their facilities that fail to comply with Medicare billing rules….we are confident that the settlements announced today will lead to increased compliance and result in significant savings to the Medicare program while protecting patient health.”[2.California HealthLine News Archive “27 Calif. Hospitals Reach Settlement With DOJ Under False Claims Act.” (Retrieved Nov. 4, 2015).]

Contact Berger Montague today

If you are aware of healthcare fraud or suspicious billing procedures such as those described above, please do not hesitate to contact Berger Montague today to learn more about healthcare fraud claims.