Few patients enjoy going to the hospital. Even fewer want to face surgery and the long recovery that usually occurs afterwards. Three whistleblowers (two doctors and a medical technician) accused the University of Pittsburg Medical Center and several physician groups of “encouraging and promoting the performance of medically unnecessary surgeries.” Without admitting any wrongdoing, the hospital and several affiliated medical providers have agreed to pay $2.5 million to settle the charges.
The case was only partially resolved leaving the prospect that the defendants may have to pay even more.
Whistleblower Suit Against UPMC
The original complaint against the hospital was filed in 2012. It was filed by two doctors, Wiiliam Bookwalter III, M.D. and Robert Sclabassi M.D., and a surgical technician, Anna Mitina. All three had worked in the hospital system. The three say that UPMC’s neurosurgical department is one of the highest grossing in the nation. In 2009 they say it was the highest grossing. At the time the complaint was filed in 2012, UPMC had grown to a $12 billion operation.
How did UPMC’s neurosurgical billings get so high? According to the three whistleblowers, it was because of expensive and unnecessary surgeries.
It isn’t just the hospital that is grossing so much money. The people who work there were raking it in as well. The hospital’s CEO made more than $6 million that year. Two neurologists made between $2.2 and $2.7 million.
The three whistleblowers attribute the financial success to “fraudulent practices that run afoul of the Medicare [and] Medicaid… statutes.”
Part of their claims involved surgeries performed by residents or physician assistants without the involvement or supervision of a teaching physician. The hospital was caught red handed doing this by the Department of Health and Human Services in 1998. Apparently that didn’t stop the wrongdoing.
The whistleblowers claim that beginning in 2006, UPMC began a campaign to increase the number of neurosurgical procedures. More surgeries means more revenues.
To insure more surgeries, the hospital system tied a doctor’s compensation to his or her “production.” If you meet production goals, you keep your high salary. Fall short and your pay is docked. Exceed your quota and you receive bonuses. (One doctor reportedly received $4 million, most of that in bonus pay.) While this system might work for a worker in a factory, it is abhorrent for doctors to be paid based on how much they can bill. According to the whistleblowers, UPMC was putting profits ahead of patient care.
If the neurologists were sending more patients for complex surgeries, other areas of the hospital system also gained. More surgeries mean more radiology procedures, more lab work, more operating room charges, more nursing care, etc. Everyone wins.
Everyone, except the patients and taxpayers. Since this case is about Medicare, Medicaid and Tricare, taxpayers are the ones footing the bill.
Many people believe that Medicare fraud is a victimless crime. In a case of unnecessary surgeries, it is easy to see how misplaced that belief is.
Not only does paying doctors for “production” lead to unnecessary surgeries, it also results in more complex surgeries. Doctors suddenly have an incentive to perform a more complex and invasive procedure even if a lower cost, simple procedure is available. That almost always means an increased risk of complications, infections, pain, suffering and sometimes death.
Case Settles for $2.5 Million
The Department of Justice intervened in the case and settled some of the allegations. The settlement requires the hospital system to pay $2.5 million.
In settling the case, the hospital was not forced to admit guilt.
A spokesperson for the Justice Department said, “Today’s settlement demonstrates our commitment to protecting federal healthcare programs from fraud. By pursuing false claims act cases like this, we send a clear message that health care providers must follow the rules when they deal with federal healthcare programs, and that this office will hold accountable those who do not.”
Not all aspects of the case have resolved meaning their could be more payments.
Whistleblowers and False Claims Act Rewards
The case against UPMC was filed under the federal False Claims Act. That law allows private individuals to file a lawsuit in the name of the United States. 29 states have similar laws, unfortunately Pennsylvania is not one of those states.
A whistleblower having inside or “original source” information about fraud against a federally funded healthcare program can file a claim in federal court. The claims are sealed meaning they are secret while being investigated by the government.
Generally the first whistleblower to file is the one that receives the award. A group of whistleblowers can file too, that is what happened in this case.
If the whistleblower’s information leads to a recovery by the government, the whistleblower can receive between 15% and 30% of what the government collects. In a case like this, that can mean over $800,000.
MahanyLaw – Medicare and Medicaid Fraud Whistleblower Lawyers
Collecting a big award means having the right inside information and finding the right lawyers. At Mahany Law, we combine decades of legal, prosecutorial and law enforcement knowledge together to create winning cases for government prosecutors. And if the government does not intervene, we put our litigation experience on the line to prosecute the case ourselves.
If you would like more information, feel free to visit our Medicare fraud whistleblower page. Better yet, contact us directly. All inquiries are protected by the attorney – client privilege and kept confidential. And there is never a charge for our services unless we recover money for you.
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