Nolan Auerbach & White are experienced Hospital Fraud Attorneys helping courageous whistleblowers.
Confirmed by a recent HHS-OIG Report, inpatient admissions related to short-stay hospital claims involving canceled elective surgeries that are not reasonable and necessary, constitutes Medicare fraud.
Under Medicare regulations, such admissions are only billable when a clinical condition existed on admission or a new condition emerged after admission that required inpatient medical care. For instance, after the beneficiary was anesthetized, the beneficiary developed a new cardiac condition, the symptoms and treatment of which warranted an inpatient admission.
Reviewing a sample of relevant claims from 2009-2011, HHS-OIG determined that a disturbing 80% of the claims were not medically reasonable and necessary.
Of particular note, HHS-OIG determined that many of the offending hospitals had not established utilization review controls to confirm whether inpatient admissions remained reasonable and necessary after an elective surgery was canceled.
Federal regulations require hospitals to have a utilization review plan that provides for review of services that each hospital furnishes to Medicare beneficiaries. (42 CFR § 482.30.) If a hospital recklessly disregards this requirement and allows false short-stay claims to flow to Medicare, the hospital is potentially liable for treble damages and hefty fines for violating the federal False Claims Act.
Kathleen Hawkins, RN MSN, had been employed by Defendant, Catholic Healthcare West (CHW) for approximately 6 years when she decided she had had enough of trying to change the hospital system from within.
CHW, a California not-for-profit corporation that operated hospitals in California, Arizona, and Nevada, was at the time the eighth largest hospital system in the nation and the largest not-for-profit hospital provider in California.
Joe Strom contacted us in 2005. We were very grateful that he did. We immediately formed an all-star legal team and a process to stop a very harmful pharmaceutical marketing strategy. It was this process we set into motion that ultimately returned hundreds of millions of dollars to the U.S. Treasury, and a portion of that, very well-deserved, into Joe’s bank account.
Joe told us a very troubling story about the off-label promotion of a pharmaceutical drug for patients who already suffered from chronic heart failure.
Bruce Moilan was a seasoned hospital systems expert by the time he contacted our Firm. At the time he decided to file his qui tam lawsuit, he was employed by South Texas Health System as a System Director for Materials Management. In this position, he oversaw $24 million in annual purchases of supplies and equipment and helped determine budget, reduction and cost analysis throughout the contract bidding and negotiations process. His job was to insure proper implementation for purchasing, receiving and management of inventory, for McAllen Hospitals, L.P.
