The U.S. Attorney’s Office for the Eastern District of Kentucky announced on January 28, 2014 that a Kentucky hospital has agreed to pay the United States $16.5 million to resolve civil claims that it submitted fraudulent claims to Medicare and to Kentucky Medicaid programs for medically unnecessary heart procedures, including unnecessary coronary stents. Other alleged unnecessary medical procedures involved pacemakers, coronary artery bypass graft surgeries, and diagnostic cardiac catheterizations.
The hospital had entered into an exclusive arrangement in 2008 with a cardiology physician group to provide cardiology services to patients at the hospital. It was alleged that from January 1, 2008 until August 31, 2011, several cardiologists working at the hospital had performed unnecessary invasive cardiac procedures on patients at the hospital that were billed to Medicare and Kentucky Medicaid for which the hospital received between $10,000 and $15,000 per procedure.
The claim of unnecessary medical procedures being billed to federal health care programs came to the attention of the U.S. Government when three whistleblowers, all of whom were cardiologists from Lexington, Kentucky, filed a federal complaint under the qui tam provisions of the False Claims Act. The three whistleblowers will receive $2,458,810 from the $16.5 million settlement, pursuant to federal law. The civil proceeding will continue against the other defendants named in the False Claims Act complaint.
One of the hospital’s cardiologists had previously pleaded guilty to performing unnecessary coronary stent procedures and had received a prison sentence of 30 months.
The settlement with the hospital also resolves claims that it violated the federal Stark Law and Anti-Kickback Statute by entering into sham management agreements with the physicians that allegedly were improper inducements for the physicians to refer patients to the hospital. As a result of the improper agreements, the U.S. alleged that Medicare and Kentucky Medicaid programs had paid claims arising out of the improper financial relationship between the physicians and the hospital.
As part of the settlement, the hospital also agreed to enter into a Corporate Integrity Agreement with the Department of Health and Human Services, Office of Inspector General (“HHS-OIG”) that requires the hospital to make substantial internal compliance reforms and to commit to a third-party review of its claims to federal health care programs for the next five years.
In announcing the settlement between the U.S. and the hospital, the U.S. Attorney for the Eastern District of Kentucky stated, “We all rely on health care providers to make treatment decisions based on clinical, not financial, considerations. The conduct alleged in this case violates that fundamental trust and squanders scarce public resources set aside for legitimate health care needs. We will use every available tool to protect our federal health care programs and the patients who they serve.”
Source: U.S. Attorney’s Office – Eastern District of Kentucky Press Release
If you are aware of improper billing to Medicare or Medicaid for unnecessary medical procedures, such as unnecessary stents, catheterizations, or coronary artery bypass graft surgeries, you may become a whistleblower and be entitled to share in a portion of the amount that the U.S. recovers as a result of your information/efforts.
Click here to visit our website or call us toll-free at 800-295-3959 to be connected with whistleblower lawyers (also known as qui tam lawyers or False Claims Act lawyers) who may investigate your whistleblower claim for you and file a federal False Claims Act complaint on your behalf, if appropriate.
Turn to us when you don’t know where to turn.