When Medicare patients could reasonably be treated on an outpatient basis but are admitted for inpatient care, the result is more expense for the government with no reason to expect a better outcome. Furthermore, patient admitting decisions should always be made for medical reasons, not to drive up reimbursements.
That is why the Justice Department's Civil Division recently brought a False Claims Act case against Banner Health. The company owns and operates some 28 acute-care hospitals in a number of states, but the allegedly false claims against Medicare occurred at 12 facilities in Arizona and Colorado Between 2007 and 2016.
Banner Health just settled the case and has agreed to pay over $18 million. It has also entered into a corporate integrity agreement. The settlement also resolves allegations that the company inflated its reports to Medicare about how many hours for which patients received outpatient observation.
The corporate integrity agreement Banner Health signed is with the Department of Health and Human Services. According to the terms of the agreement, the company is required to retain an independent organization to review, for accuracy, Banner Health's claims for medical services provided to federal healthcare program beneficiaries.
"Hospitals that bill Medicare for more expensive services than are necessary will be held accountable," said a spokesperson for the U.S. Department of Health and Human Services' Office of the Inspector General.
The lawsuit against Banner Health was originally filed by a former employee. The qui tam provisions of the False Claims Act allows private citizens to bring such lawsuits on behalf of the United States when they have credible evidence of fraud, waste or abuse involving a government program. In exchange, whistleblowers can receive a percentage of whatever recovery is made in the case. In this case, the former employee will receive approximately $3.3 million.
If you work for an organization that contracts with a state or the federal government, you may be in a position to fight wrongdoing by filing a whistleblower lawsuit. However, it is a good idea to speak with an experienced whistleblower attorney in order to ensure you maintain your eligibility for any award and to limit the chance of employer retaliation.