Posts Tagged ‘Adventist Health System’

$18 Million Settlement: IU Health/HealthNet Whistleblower Case

Dr. Judy Robinson with Tyler & Koger families.

Dr. Judy Robinson with Tyler & Koger families.

A whistleblower suit filed by Dr. Judith Robinson under the False Claims Act has led to an $18 million settlement with two of Indiana’s largest health care providers.  Indiana University Health and HealthNet have agreed to pay $18 million to the federal government and State of Indiana to resolve illegal kickback and false billing claims.  Dr. Robinson, a client of James Hoyer, P.A., filed the whistleblower lawsuit in 2013.

In June, Dr. Robinson met with moms and children harmed during childbirth at IU’s Methodist Hospital. Click here to watch the story by WTHR’s 13 Investigates Reporter Sandra Chapman.

The Whistleblower

Dr. JudithRobinsonPicDr. Judith Robinson is a prominent Indianapolis Ob/Gyn and former employee of both IU Health and HealthNet, a Federally Qualified Health Center (FQHC), which primarily provides services to low income populations.  Her goal was to expose what she believed was substandard care being provided to pregnant women and babies on Medicaid.  This settlement is an important step toward protecting those women and babies.

“I’m grateful this case has shined a light on the care that was provided to low income pregnant women and their babies. I’m hopeful the changes caused by this settlement will help to ensure our community’s most vulnerable patients get the care they need and deserve,” Dr. Robinson said.

Dr. Robinson is represented by Attorney Jillian Estes, a partner at the James Hoyer law firm.

“Dr. Robinson made a real difference because of her courage to come forward,” said Attorney Estes. “Pregnant women and babies in Indianapolis are safer today because of her decision to become a whistleblower.”

The Settlement

The settlement covers three areas, including:

  • Inappropriate billing when Certified Nurse Midwives (CNMs), instead of doctors, cared for high risk pregnant women, in violation of Indiana Medicaid rules;
  • Kickback claims, regarding various financial schemes between IU Health and HealthNet, which improperly induced referrals; and
  • False claims for “wrap around” payments, which are payments made to FQHCs to supplement their care to the poor.

In addition to the $18 million dollars being paid for the settlement, HealthNet has agreed to a Corporate Integrity Agreement with the federal government related to the kickback allegations, which requires HealthNet to restructure and maintain complete independence from IU Health.  HealthNet also signed a separate, side agreement with the State of Indiana, which requires HealthNet to bill only for care to high-risk pregnant women provided by a physician or under a physician’s direction.

“It’s important to note that as part of the settlement, HealthNet has been forced to change its conduct in how it operates and how its CNMs care for high-risk pregnant women,” Attorney Estes said. “We hope these agreements, along with regular monitoring, will ensure that patients will be protected for years to come.”

Certified Nurse Midwife Claims

The suit, filed under the federal and Indiana False Claim Acts, alleged that IU Health and HealthNet violated Indiana Medicaid rules to save money by using CNMs, instead of doctors,  to care for medically high-risk pregnant women.

“Patient care has to come first, not money,” Dr. Robinson said.  “Midwives can provide excellent care to low-risk patients, but when it comes to high-risk pregnancies, the danger for complications requires a doctor’s attention. It’s important to me that these moms and babies get the care they need to keep them safe.”

In Dr. Robinson’s unique position as both Director of Women’s Services for HealthNet and Medical Director of Ob/Gyn Services at Methodist Hospital/IU Health, she became aware of CNM care she believed was putting patients at risk.  Dr. Robinson documented 3 instances of babies suffering permanent neurological damage and 17 “near misses” in just 6 months as a result of care to high-risk patients by CNMs. When her efforts to change the system fell on deaf ears, Dr. Robinson was ostracized and ultimately fired.  She then learned that the billing for CNM care of high-risk patients violated Indiana Medicaid rules and felt compelled to bring her information forward to the government.

Kickback Claims

Anti-kickback laws are essential to discouraging physicians from accepting financial incentives for referring patients, which can lead to unnecessary medical services and increased overall healthcare costs. This whistleblower suit alleged that IU Health paid illegal kickbacks to HealthNet to induce a steady stream of referrals to Methodist Hospital from its FQHC clinics. A variety of financial schemes were at the center of the kickback allegations, including:

  • IU Health providing an ever-increasing line of credit to HealthNet, which ballooned to nearly $14 million, with no strict requirement for payback;
  • IU Health giving HealthNet a sweetheart deal for rent, charging just $1 a year; and
  • IU Health paying to open and subsidize operation of a high-risk maternity clinic for HealthNet, with the understanding that critically ill newborns would be sent to IU’s Methodist Hospital Neonatal Intensive Care Unit, and not to other area NICU’s, as a scheme to make more money for IU Health off of sick babies.

“These hidden financial arrangements and sweetheart deals were not only illegal and costly to Indiana taxpayers, but also inappropriately restricted patient choice on where to get care,” said Attorney Estes. “Now, patients can be referred to the hospital that can best provide care, not just the hospital with financial connections to the clinic.”

Ultrasound Claims

The $18 million settlement also resolves claims from 2005 to 2010 that HealthNet inappropriately received extra payments provided to FQHC’s for physicians to read ultrasounds.  To get the so-called “wrap-around” payments, doctors were required to meet face-to-face with patients, which they did not do.  Additional wrap-around payments for claims made from 2011 to 2015 were also settled, but are still being calculated.  The value of these claims is estimated at $1.4 million.

False Claims Act

The federal False Claims Act provides for private citizens to file suit on behalf of taxpayers when they become aware of fraud against the government.  Whistleblowers receive a portion of the funds returned as a reward for exposing the fraud.

“The False Claims Act is an important tool for the government to fight fraud with the help of whistleblowers,” said Attorney Estes. “It’s very easy for a private citizen who sees wrongs to look the other way, but Dr. Robinson didn’t do that. She did the right thing, and with her help, millions of dollars will be returned to the taxpayers.”

The settlement was reached through a joint effort between Dr. Robinson, her attorneys, and attorneys from the United States Department of Justice and State of Indiana.  Dr. Robinson and her counsel are particularly grateful to Assistant U.S. Attorney Jonathon Bont for his efforts throughout the case in helping to attain a successful resolution.


Adventist Health Pays $118 Million to Settle Whistleblower Case

The Department of Justice announced one of the largest False Claims Act settlements ever over Stark Statute violations, related to improper compensation to doctors for referrals.  Adventist Health System has agreed to pay more than $118 million to settle allegations from multiple whistleblowers.  The U.S. government will receive $115 million and $3.75 million will go to the states of Florida, North Carolina, Tennessee and Texas.  Here is the DOJ news release:

Adventist Health System Agrees to Pay $115 Million to Settle False Claims Act Allegations

Adventist Health System has agreed to pay the United States $115 million to settle allegations that it violated the False Claims Act by maintaining improper compensation arrangements with referring physicians and by miscoding claims, the Justice Department announced today.  Adventist is a non-profit healthcare organization that operates hospitals and other health care facilities in 10 states.

“Unlawful financial arrangements between heath care providers and their referral sources raise concerns about physician independence and objectivity,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division.  “Patients are entitled to be sure that the care they receive is based on their actual medical needs rather than the financial interests of their physician.”

The settlement announced today resolves allegations that Adventist submitted false claims to the Medicare and Medicaid programs for services rendered to patients referred by employed physicians who received bonuses based on a formula that improperly took into account the value of the physicians’ referrals to Adventist hospitals.  Federal law restricts the financial relationships that hospitals and clinics may have with doctors who refer patients to them.

“Adventist-owned hospitals, such as Park Ridge, allegedly paid doctors’ bonuses based on the number of test and procedures they ordered,” said Acting U.S. Attorney Jill Westmoreland Rose of the Western District of North Carolina.  “This type of financial incentive is not only prohibited by law, but can undermine patients’ medical care.  Would-be violators should take notice that my office will use the False Claims Act to prevent and pursue health care providers that threaten the integrity of our healthcare system and waste taxpayer dollars.”

“Companies that financially reward physicians in exchange for patient referrals – as the government contended in this case – undermine the physicians’ impartial medical judgment at the expense of patients and taxpayers,” said Special Agent in Charge Derrick L. Jackson of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) in Atlanta.  “We will continue to investigate such wasteful business arrangements.”

The settlement also resolves allegations that Adventist submitted bills to Medicare for its employed physicians’ professional services containing certain improper coding modifiers, and thereby obtained greater reimbursement for these services than entitled.

The allegations settled today arose from two lawsuits filed respectively by whistleblowers Michael Payne, Melissa Church and Gloria Pryor, who worked at Adventist’s hospital in Hendersonville, North Carolina, and Sherry Dorsey, who worked at Adventist’s corporate office, under the qui tam provisions of the False Claims Act.  The act permits private parties to file suit on behalf of the United States for false claims, and to share in any recovery.  The whistleblowers’ share of the settlement has not yet been determined.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $25 billion through False Claims Act cases, with more than $16 billion of that amount recovered in cases involving fraud against federal health care programs.

The cases, United States ex rel. Payne, et al. v. Adventist Health System/Sunbelt, Inc., et al. No. 12-856 (W.D.N.C), and United States ex rel. Dorsey v. Adventist Health System Sunbelt Healthcare Corp., et al., No. 13-217 (W.D.N.C), were handled by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office of the Western District of North Carolina and HHS-OIG.  The claims settled by this agreement are allegations only, and there has been no determination of liability.