Posts Tagged ‘Prime Healthcare’

James Hoyer Client Named 2018 Whistleblower of the Year

Karin Berntsen

James Hoyer, P.A. is proud to announce that our client Karin Berntsen was named Whistleblower of the Year at the annual Taxpayers Against Fraud awards dinner, in Washington, D.C. This marks the second time in the past three years that a James Hoyer client has been bestowed with this great honor.

Ms. Berntsen blew the whistle on Prime Healthcare, the 5th largest healthcare system in the country, exposing evidence of improper billing and upcoding which she believed was putting patients at risk and abusing taxpayer dollars. Her fearless, tireless, seven-year commitment to the case resulted in the company paying $65 million dollars to settle civil charges of fraud against the government.

I am very honored to be selected as the 2018 Whistleblower of the Year by Taxpayers Against Fraud,” Ms. Berntsen said. “It wasn’t easy, but sometimes that makes you more determined. The more obstacles I had, the stronger it made me.  I knew the taxpayers were being cheated and the patients were put at risk, so coming forward was just the right thing to do.”

It took incredible courage and perseverance for Ms. Berntsen to continue with the case for seven long years, despite extreme personal hardship, which included serious illnesses, surgeries, and hospitalizations. Nevertheless, she endured through it all, remaining in place as an employee at Prime’s Alvarado Hospital in San Diego and wearing a wire for the FBI on multiple occasions to record evidence.

Partner Elaine Stromgren accepts the Whistleblower of the Year Award on behalf of James Hoyer client Karin Berntsen

“Karin’s dedication to justice was unwavering. I cannot imagine a more deserving individual for this prestigious honor. She put her career on the line against a powerful company, but through it all, she remained strong,” said James Hoyer Partner Elaine Stromgren, Ms. Berntsen’s lead attorney, who accepted the award on her behalf at the TAF dinner Thursday night in Washington, D.C.

Ms. Berntsen has dedicated her life to ensuring patient safety. She began her career as a registered nurse, then served as a patient safety officer, and also authored two published books on patient safety before eventually becoming Director of Performance Improvement at Alvarado Hospital. Her concern for the well-being of the patients was one of her main motivations for coming forward as a whistleblower.

“I continually witnessed blatant healthcare fraud at the highest level of the organization. The patients were becoming commodities. They were becoming dollar signs, not people,” Ms. Berntsen said.

Ms. Berntsen expressed her appreciation for receiving the award in a videotaped statement played at the awards dinner because she was unable to attend due to a recent surgery. Here is an excerpt:

“When my complaints fell on deaf ears and my job was threatened, I researched my options and found the James Hoyer investigative law firm. They had a solid record of success and stellar professionals working there.

I interviewed with Al Scudieri a retired FBI agent with a wealth of experience. My attorney Elaine Stromgren worked tirelessly with other attorneys and the government to expose the fraud at this organization.

Attorneys Clark Bolton, Elaine Stromgren & Jesse Hoyer at the TAF awards dinner.

It took seven years, and we were eventually headed toward trial, but with the work of many, we reached a successful settlement this year. I am very grateful to that team.  I want to say a very special thank you to Taxpayers Against Fraud for this wonderful recognition.”

Please join James Hoyer in congratulating Karin for this deserving recognition.

“We are proud to stand beside Karin and grateful we could assist her in this important battle on behalf of patients and taxpayers,” Stromgren said. “The courage it takes to become a whistleblower is enormous, and we hope her success will inspire others to come forward to do the right thing when they witness fraud against the government.”

Click here to view Karin’s acceptance of the Whistleblower of the Year award.


$65 Million Prime Healthcare Whistleblower Settlement

Prime Whistleblower

Whistleblower’s Fearless 7-Year Pursuit of Justice:

Los Angeles, CA- August 3, 2018— The 5th largest for-profit hospital system in the country has agreed to pay $65 million to settle civil charges of healthcare fraud against the government. Prime Healthcare has also agreed to abide by a Corporate Integrity Agreement with strict requirements and oversight to ensure it will follow Medicare rules in the future. Prime, headquartered in Ontario, CA, has 45 hospitals in 14 states. It was a long-fought battle against the healthcare giant lasting nearly a decade, but whistleblower Karin Berntsen is grateful to finally see Prime held accountable.  Read More…


Prime Healthcare Loses Motion to Dismiss: Whistleblower Case Moves Forward

A blow was dealt to Prime Healthcare as a California federal court issued three rulings denying motions filed on behalf of the hospital corporation. As a result, an important whistleblower case, alleging Prime inappropriately admitted patients to increase profits, will move forward.

“This is a very important ruling,” said James Hoyer Law Firm Partner Elaine Stromgren, who represents whistleblower Karin Berntsen, a Prime employee. “The evidence, supporting Ms. Berntsen’s and the government’s allegations, is very strong,” added Stromgren.  Ms. Berntsen is Director of Performance Improvement at Alvarado Hospital Medical Center in San Diego.

Prime Healthcare is one of the fastest growing hospital corporations in the country, which operates more than 40 hospitals in 14 states. The company is known for using aggressive tactics to buy underperforming, financially distressed hospitals and then implementing cost-cutting measures to make money.

According to the government, “Defendants implemented a scheme to maximize revenues by improperly admitting Medicare patients into the hospital who should not have been admitted so that they could charge Medicare three to four times what they would have been able to charge had the patients merely been observed in the hospital and allowed to go home,” U.S. Magistrate Judge Patrick Walsh of the Central District of California explained in his order.

The Court noted that the government alleges Prime’s founder and Chief Executive Dr. Prem Reddy used several tactics to improperly influence the medical decisions of the doctors. The complaint alleges those efforts included removing the choice of “observation” from hospital forms; telling doctors what to write in patient medical charts to justify unnecessary admissions; establishing quotas on the number of patients admitted; and retaliating against doctors if those quotas were not met.

Becker’s Hospital Review and Modern Healtcare reported on the decision.

Motion to Pre-empt Statistical Sampling Denied

In addition to denying the Motion to Dismiss, the Court also denied a motion filed by Prime to pre-empt the government from using expert, statistical analysis to prove its case.

The government estimates more than 35,000 patients were improperly admitted at 14 Prime hospitals in California, resulting in false billings to Medicare. With such large numbers, statistical sampling is often used to extrapolate results.

Amicus Briefs “unhelpful”

Lastly, the Court denied requests by the American Hospital Association and the California Hospital Association to submit Amici Curiae briefs in the case. The Court indicated the briefs merely complained about the complexity of regulations governing outpatient observation versus inpatient hospitalization, without presenting any new or helpful information.

The Court agreed with the government’s contention that the briefs were “unhelpful” and, therefore, denied the motion.

“We are pleased that this important case will be allowed to proceed,” Attorney Stromgren said. “We have strong evidence to show Prime manipulated the system to get millions of dollars in improper payments from Medicare.”

Upcoding Allegations Proceed

In addition to the medically unnecessary inpatient admission portion of the case, Whistleblower Karin Berntsen will continue to pursue allegations of “upcoding” by Prime. Berntsen alleged in her complaint that Prime hospitals improperly upcoded and falsified patient diagnoses, which resulted in unlawful billings to the federal government. Defendants’ challenge to that portion of the case in an earlier motion also failed.


Federal Government Joins Prime Healthcare Whistleblower Suit


Prime Healthcare Whistleblower Karin Berntsen

The federal government is joining the whistleblower case of James Hoyer client Karin Berntsen against Prime Healthcare Services, its founder Dr. Prem Reddy, and more than a dozen of its hospitals.  Prime is a fast growing company that owns more than 40 hospitals nationwide.

The whistleblower suit, which was unsealed in December of 2013, alleges Prime improperly admitted patients through its emergency rooms to increase payments from Medicare.

James Hoyer partner Elaine Stromgren called the government’s intervention “a significant development which shows the seriousness of the allegations and the strength of the evidence supporting those claims.”

The Department of Justice news release explains some of the key allegations:

The lawsuit alleges that Dr. Reddy directed the corporate practice of pressuring Prime’s Emergency Department physicians and hospital administrators to raise inpatient admission rates, regardless of whether it was medically necessary to admit the patients.  The lawsuit alleges that Prime’s corporate officers, at Reddy’s direction, exerted immense pressure on doctors in the Emergency Departments to admit patients who could have been placed in observation, treated as outpatients or discharged.  As a result of these medically unnecessary admissions from the Emergency Departments, Prime hospitals allegedly submitted false claims to federal health care programs, such as Medicare.

Whistleblower Karin Berntsen remains in her position at Alvarado Hospital in San Diego as Director of Performance Improvement.  She came forward to expose these practices because she believes they put  patients at risk in order to increase profit.

DOJ says the government’s intervention in this case shows its emphasis on combating health care fraud:

“The Department of Justice is committed to ensuring that health care providers do not inappropriately seek to profit at the expense of federal health care programs,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division.  “Schemes such as this one can contribute significantly to the rising cost of health care delivery and create needless patient risk.”

“Fraudulent billing practices, such as those alleged in this civil lawsuit, harm taxpayers who fund health care programs, such as Medicare,” said U.S. Attorney Eileen M. Decker for the Central District of California.  “The Justice Department works collaboratively with law enforcement agencies, regulators and, in some cases, private citizens to ensure the integrity of a system that provides healthcare to millions of Americans.”

“Charging for medically unnecessary services, as alleged in this case, raises costs in government health programs and remorselessly passes that bill along to taxpayers,” said Special Agent in Charge Christian J. Schrank of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG).  “Our investigation into the allegations in this case, along with our law enforcement partners, led to the government’s decision to intervene.”

Contact Us ButtonThe whistleblower suit also alleges that Prime would “upcode” patient diagnoses to make them appear more serious, in order to get additional Medicare payments.  The James Hoyer firm will continue to vigorously pursue this count as well.

Multiple news outlets reported on the significant development, including the Center for Investigative Reporting, Wall Street Journal, Los Angeles Times, San Diego Union TribuneModern Healthcare, and Becker’s Hospital Review, among others.


James Hoyer Prime Hospital Case Takes Major Step Forward

Prime Whistleblower

Karin Berntsen – James Hoyer Client

The whistleblower case filed against Prime Healthcare by James Hoyer client Karin Berntsen has cleared a major hurdle.  The defendant’s Motion to Dismiss the case was denied in its entirety.  Judge Patrick Walsh of the U.S. District Court for the Central District of California wrote:

Based on these allegations, the Court is satisfied that Berntsen has stated an FCA (False Claims Act) claim with sufficient particularity as against all Defendants. Having carefully reviewed the FAC, the Court finds that it includes the who, what, when, where, and how of the alleged fraud.

The San Jose Mercury News wrote about the decision in an article, Controversial hospital chain owner poised to expand empire to Bay Area, about the hospital chain’s rapid expansion.  The article outlined the allegations in Berntsen’s complaint against Prime Healthcare:

Karin Berntsen, who gathered information during meetings with Reddy, alleges in the civil suit that Prime hospitals admit patients when medically unnecessary; “upcode” — that is, falsify patient records and billing codes to increase reimbursement; and, in order to make more money, often refuse to discharge patients or transfer them to another hospital.

The article goes on to further explain the allegations:

Berntsen is a veteran registered nurse, author of a book on patient safety and is currently the director of performance improvement at Alvarado Hospital in San Diego. In her suit, she accuses Reddy, as well as the hospital’s CEO and 14 of Prime’s California hospitals, of bilking the federal government of at least $50 million.

Click here to read the entire article in the San Jose Mercury News.