Re: Government Alligations Of Fraudulant Billing By The University Of Chicago
From: art fougner, md (evsono@pipeline.com)
Mon Mar 15 08:27:26 1999
the clinton justice dept has no biz callin anyone fraudulent.
art
"of course, that's just my opinion. i could be wrong."
Dennis Miller
At Mon, 15 Mar 1999, Dean Huffman wrote:
>
>I have not yet seen this posted, so I am putting it out here to
>stimulate some discussion. It is about billing for all medical items,
>not just OB/GYN, but it should be of general interest to the OB/GYN
>community, too.
>
>- - - - - - - - - - - - - - - - - -
>
>U.S. Sues U. of C. In Medicare Overbilling.
>
>Liability could run up to $100 million.
>
>Chicago Tribune 3/14/1999
>
>By Jeremy Manier, Tribune STAFF WRITER
>
>In a major action against one of the Midwest's premier medical research
>institutions, the federal government has brought a civil suit alleging
>that the University of Chicago knowingly engaged in a "pattern and
>practice" of fraud and overbilling in the hospital's Medicare and
>Medicaid claims.
>
>Among other allegations, the federal suit maintains that fully 40
>percent of the most expensive outpatient Medicare claims submitted by
>the U. of C. between 1991 and 1997 were fraudulently "upcoded" to bilk
>the government out of millions of dollars.
>
>Although government lawyers have not set a price tag for damages, a
>similar set of charges against the University of Pennsylvania was
>settled in 1995 for $30 million. Private attorneys involved in the case
>said the U. of C. could be liable for far more than that -- as much as
>$30 million -- if the suit goes to trial.
>
>The case began in 1996 with a sealed complaint filed by a whistle-blower
>at the hospital. It was
>unsealed only recently, when the US attorney's office 'in Chicago
>brought its suit following a 1 1/2-year investigation and audit by the
>Illinois Department of Public Aid.
>
>The U. of C. is fighting the charges.
>
>"We deny any allegations of improper billing to Medicare or any other
>payer," hospital spokesman John Easton said Friday.
>
>The U. of C. is the latest target in a coordinated effort by the
>Clinton administration to root out health-care fraud and abuses, and the
>first major Chicago hospital to be hit.
>
>Launched in earnest after the president's health-care reform plan failed
>in 1994, the effort has netted billions in rewards and settlements.
>Atty. Gen. Janet Reno has placed fighting health care fraud as her
>second-highest priority next to prosecuting violent crime, officials
>say.
>
>Most recently, Blue Cross and Blue Shield of Illinois pleaded guilty
>last July to defrauding Medicare and agreed to pay $144 million-the
>largest fraud penalty ever levied against a Medicare claims processor.
>
>In its formal response filed in court, the U. of C. contends that
>previous refund payments the hospital made to Medicare and Medicaid
>should cover any current claims by the government
>
>"To the extent claims at issue in this complaint were the subject of
>previous audits resulting in refund payments to the Medicare and/or
>Medicaid programs, defendants have been released of any liability for
>such claims," the U. of C. states in its response to the federal
>complaint.
>
>The hospital paid $1 million to the state Public Aid Department in 1996
>for overcharges in Medicaid services, according to Robb Miller, the
>department's inspector general. The state did not address whether the
>overbilling was intentional.
>
>Furthermore, the defense lawyers argue, the law governing proper billing
>is too vague and changes too often to be fairly enforced.
>
>Even so, said James Sheehan, chief of the civil division of the U.S.
>attorney's office in Philadelphia, which brought the successful suit
>against Penn, such cases are rarely brought unless the government claims
>to have proof the, overbilling was intentional.
>
>"You have to assume you're not going to join a major case against a
>major teaching institution unless you have pretty strong evidence to
>support it" Sheehan said.
>
>Upcoding, in which hospitals bill federal programs at a higher rate than
>is warranted by the procedures performed, has been found at many
>otherwise prestigious medical institutions around the country. Besides
>Penn, the University of Virginia, the University of Pittsburgh and the
>University of Texas at San Antonio all have settled multimillion-dollar
>upcoding suits brought by the government since 1997.
>
>"Upcoding is a generous word for fraud," said Steven Cohen, an ,attorney
>representing the whistleblower who brought the original suit against the
>U. of C. He said his client did not want to be interviewed until the
>case was resolved.
>
>The offense of upcoding involves manipulating the complex federal
>billing system For Medicare, part of the system consists of five codes
>that correspond to different rates of reimbursement from the government.
>Services fall under one of the codes depending on how much time and
>effort the staff spends treating a patient and the severity of the
>patient's condition.
>
>For example, if an outpatient comes in for a minor visit to treat a cold
>or for a routine checkup, the visit likely would warrant the lowest
>coding. With the highest two codes, Medicare assumes the physician
>spends at least 80 minutes with a patient. Someone who came in for an
>outpatient operation would likely receive the highest code.
>
>Upcoding occurs when an institution bills the government for a high code
>when the services provided are actually worth a, lower billing rate.
>
>"Fraud is fraud, no matter who does it," said Linda Wawzenski, an
>assistant U.S. attorney in charge of civil fraud cases in the Chicago
>district who is leading the case against the U. of C.
>
>Until the last few years, however, the government did not aggressively
>enforce laws against such practices.
>
>In the U. of C.'s case, the government alleges that upcoding for
>outpatient services was blatant and was done with knowledge that the
>codes had been falsified.
>
>The federal complaint cites a billing sheet used by one of the
>institution's hematology and oncology clinics that contained spaces for
>only the two highest billing codes. The government contends that
>doctors in that department had no choice but to upcode for services that
>should have fallen under the lower three codes.
>
>In at least that department the suit alleges: "Doctors were only given
>the option of charging the two highest codes for outpatient services for
>Medicare patients, regardless of the actual level of the service
>performed."
>
>The suit names as defendants the university, the U. of C. Physicians
>Group and the U. of C. Hospitals.
>
>Between 1991 and 1997 for Medicare claims and between 1991 and 1995 for,
>Medicaid, the suit alleges, the "defendants engaged in a Pattern and
>practice of submitting and causing others to submit false and fraudulent
>claims ... knowing that these billings were false or acting in reckless
>disregard for the truth."
>
>Under the federal False Claims Act, which is the basis of the U. of C.
>suit the government is entitled to triple the amount it was falsely
>overcharged, plus a $5,000 to $10,000 penalty for each individual false
>claim.
>
>The resulting penalty for the U. of C. could be massive if the case
>goes to trial rather than being settled out of court Judge Blanche M.
>Manning has set May 30 as the discovery cutoff date; the trial itself
>would begin in early November.
>
>The whistleblower's lawyers estimate the base amount that the government
>overpaid the U. of C. during the period involved might have reached
>$10 million,
>
>Conceivably, the penalty component could be even greater. If, as Cohen
>estimates, some 5,000 patient charts a year between 1991 and 1997 were
>affected by Medicare or Medicaid overbilling, the penalty could exceed
>$100 million.
>
>Such daunting figures are incentive enough that all the major medical
>institutions faced with false claim suits in recent years have settled
>out of court.
>
>Amounts have ranged from $86 million paid by the University of Virginia
>to the $30 million settlement dished out by Penn.
>
>But perhaps most troubling for the institutions, the U.S. Department of
>Health and Human Services can exclude a hospital from any participation
>in Medicare and Medicaid if the government wins a false claims case in
>court. For places like the U. of C., which gets half its outpatients
>through those programs such an outcome is too catastrophic to
>contemplate, Sheehan said.
>
>As more hospitals become targets of federal fraud investigations,
>advocacy groups for doctors and medical schools have spoken out against
>what they see as a federal billing system that can be confusing and
>unfair to health-care providers.
>
>That's not to say the administration's anti-fraud efforts are all bad,
>said Robert Dickler, senior vice president for health care affairs it
>the Association of American Medical Colleges.
>
>"I would say today we have much more rigorous and extensive compliance
>programs, more adherence to the rules and regulations and a higher level
>of documentation," Dickler said. "The downside is that the whole
>process may have become so onerous that it's undercutting the
>physicians' ability to devote enough time to their fundamental duties of
>teaching and providing care."
>
>But with an estimated $27 billion lost each. year to Medicare fraud,
>government officials dispute the idea that upcoding could be entirely a
>result of innocent misreadings of unclear regulations.
>
>"If the coding was as puzzling 4s some would suggest, then why aren't
>there as many errors on the undercoding side as on the upcoding side?"
>asked Ben St. John,, a spokesman for the HHS inspector general's
>office.
>
>In any case, upcoding must be intentional for the government to win a
>suit under the False Claims Act, Sheehan said. Showing that the U. of
>C. acted with knowledge of or "reckless disregard!' for the proper
>claim amounts will be a central -- and challenging -- part Of the
>government's case.
>
>"If it's just a question of whose reading is more reasonable, the
>government loses," Sheehan said.
--
art fougner, md
SonoScan/Genetic Sciences
forest hills, ny
evsono@pipeline.com
