Nurse nails Univ. of Chicago in qui tam suit
Hospital’s liability could reach $100 million, some experts project
A private whistle-blower has latched onto the government’s investigation of teaching hospitals. The University of Chicago Hospital has been sued by a former employee whose charges mirror those leveled by OIG in its PATH (Physicians at Teaching Hospitals) initiative.
Linda Wawzenski, the assistant U.S. attorney in Chicago handling the case, dismissed reports in local papers that the hospital’s liability could reach $100 million. That would far exceed the $30 million paid by the University of Pennsylvania in the largest of the half-dozen PATH settlements. Steven Cohen, the Chicago attorney representing whistle-blower Al Reppine, says the hospital may have improperly billed Medicare and Medicaid for as much as $15 million to $20 million, but Wawzenski says that even $10 million "is on the high side." Still, the triple damages allowed by the False Claims Act could potentially put a settlement at $30 million, and that doesn’t even count any $10,000-per-claim penalties.
Reppine, a former nurse at the hospital, makes the same claims of upcoding and improper physician supervision that OIG made in its PATH investigations of other institutions. A staggering 40% of the highest-coded outpatient physician Evaluation and Management codes were upcoded by one to four E&M levels, according to the Justice Department complaint. "In at least one of the defendants’ medical departments, 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 according to the CPT codes," says DOJ.
In addition, the hospital allegedly upcoded Hospital Ambulatory Reform (HAR) codes for Medicaid patients. "In 1995, HAR procedure code 00.80 accounted for 94% of defendants’ clinic billings to Medicaid," says the complaint. Hospital spokesman John Easton would say only that the hospital denies the charges.
Yet while the government intervened in support of Reppine’s claim of upcoding, it did not buy his argument that University of Chicago doctors violated HCFA regulations that require teaching physicians to actually spend time (and document the time spent) with patients under care of residents. Wawzenski declined to say why DOJ isn’t supporting Reppine on the supervision issue.
The qui tam suit comes after the Justice Department announced a softer approach on false claims cases last year, and after OIG said it would not pursue PATH investigations in states where carriers gave unclear guidance on teaching physician regulations. "I assume that if the government saw a good case, they would have to go forward with it," says Ivy Baer, an attorney for the American Association of Medical Colleges in Washington, DC.
Wawzenski acknowledged that it is uncommon for a qui tam suit to be unsealed and made public prior to a settlement being announced. It happened in the Chicago case because the court imposed a deadline that forced the government to decide whether to intervene — and unseal the suit — or allow Reppine’s suit to proceed on its own.
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