Seven Things To Know When You Receive A Notice Of Investigation From The Department Of Health

Pennsylvania Hospital Asks Court To Dismiss FCA Suit For Billing Simultaneous Surgeries

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On November 2, 2021, the University of Pittsburgh Medical Center (UPMC) urged a Pennsylvania federal court to dismiss allegations that its physician and star surgeon submitted false medical billings. Last month, the U.S. Justice Department filed a lawsuit alleging that the surgeon who was involved unlawfully billed the government for performing surgeries on different patients at the same time. The surgeon is alleged to have caused severe harm patients in the process. The case was brought under the False Claims Act (FCA), sometimes referred to as the Qui Tam Act or whistle blowers law.

To read the press release issued by the U.S. Attorney’s Office, click here.

Can the Government State a Claim Under the False Claims Act?

According to the DOJ, UPMC violated federal law and is liable under the FCA, as well as various common law causes of action, because the surgeon allegedly:

1.    is not “immediately available” in one billed procedure when he is performing or participating in a second or third one;

2.    is not present for the surgical “time out” preceding a billed procedure; and

3.    subjects patients to unnecessary anesthesia time while he finishes a concurrent or overlapping procedure.

Additionally, the complaint says that guidelines from the Centers for Medicare & Medicaid Services (CMS), along with federal regulations for funding “teaching hospitals” like UPMC, require a surgeon to be present or immediately available for all the critical parts of an operation.

Because of the surgeon’s “room-hopping” during the operations, he allegedly violated those rules. This should have prevented him from billing government health plans for his services, the suit says.

You can view the complaint in full here.

UPMC Strongly Denies Allegations.

The university in its response criticized the suit, arguing that the government failed to state a claim under the FCA because it didn’t identify a coherent, enforceable regulatory regime governing billing for concurrent or overlapping surgeries. Additionally, UPMC argued, there are no federal regulations prohibiting surgeons from conducting simultaneous surgeries.

While acknowledging that regulations exist for teaching hospitals that require teaching physicians to be “immediately available” for “key” or “critical” parts of the procedures for which they bill, the rule doesn’t define these terms, UPMC said. Separate guidance from CMS gives teaching physicians wide latitude over how they conduct surgeries and allows surgeons to decide for themselves which portions of a procedure are critical, UPMC added in its brief.

UPMC’s spokesman Paul Wood defended the hospital reportedly stating, “the surgeon was always present for the parts of surgeries he deemed vital, and when he was absent for noncritical sections, a fully qualified attending surgeon was at hand.”

To view the brief in full on our website, click here.

Contact Health Law Attorneys Experienced in Handling Health Care Fraud Investigations and other Legal Proceedings.

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

The Health Law Firm’s attorneys routinely represent physicians, dentists, pharmacists, psychotherapists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Aquino, Alyssa. “Pa. Hospital Urges Court To Nix Simultaneous Surgery Suit.” Law360. (November 2, 2021). Web.

Hamill, Sean. “Feds in rare battle with UPMC, star doctor.” Pittsburgh Gazette. (October 21, 2021). Web.

Ove, Torsten. “U.S. accuses UPMC surgeon, physicians group of false billing.” Pittsburgh Gazette. (September 2, 2021). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law; he is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2021. The Health Law Firm. All rights reserved.

By George F. Indest III, J.D., M.P.A., LL.M.

Board Certified by The Florida Bar in Health Law

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