Hundreds of Hospitals to Reimburse the US Federal Government

Four hundred fifty-seven hospitals in 43 states have agreed to pay the US Department of Justice (DOJ; Washington DC, USA) over USD 250 million for installing implantable cardiac defibrillators (ICDs) in violation of Medicare (Baltimore, MD, USA) reimbursement protocol.

Most of the settling defendants were named in a qui tam (whistleblower) lawsuit brought under the False Claims Act, which permits private citizens to bring lawsuits on behalf of the United States and receive a portion of the proceeds of any settlement or judgment awarded against a defendant. The lawsuit was filed in federal district court in the Southern District of Florida by Leatrice Ford Richards, a cardiac nurse, and Thomas Schuhmann, a health care reimbursement consultant, who have received more than USD 38 million from the settlements. The Department of Justice is continuing to investigate additional hospitals and health systems.

“While recognizing and respecting physician judgment, the department will hold accountable hospitals and health systems for procedures performed by physicians at their facilities that fail to comply with Medicare billing rules,” said principal deputy assistant attorney General Benjamin C. Mizer, head of the DOJ Civil Division. “We are confident that the settlements announced today will lead to increased compliance and result in significant savings to the Medicare program while protecting patient health.”

“The settlements announced today demonstrate the Department of Justice's commitment to protect Medicare dollars and federal health benefits,” said US Attorney Wifredo Ferrer of the Southern District of Florida. “Guided by a panel of leading cardiologists and the review of thousands of patients' charts, the extensive investigation behind the settlements was heavily influenced by evidence-based medicine. In terms of the number of defendants, this is one of the largest whistleblower lawsuits in the United States and represents one of this office's most significant recoveries to date.”

Medicare coverage for an ICD is governed by a national coverage determination (NCD) that is based on clinical trials and the guidance and testimony of cardiologists and other health care providers, professional cardiology societies, cardiac device manufacturers, and patient advocates. The NCD stipulates a waiting period of 40 days for a heart attack and 90 days for bypass or angioplasty to give the heart an opportunity to improve function on its own, to the point that an ICD may not be necessary. The NCD expressly prohibits implantation of ICDs during these waiting periods, with certain exceptions.

Related Links:
US Department of Justice
Medicare