DOJ settles whistleblower case exposing fraudulent procedures

April 14, 2022. The United States Department of Justice has settled a case against a health care and hospital system for performing medically unnecessary neurological surgeries and billing federal health care programs for them. According to the regulations, Providence Health & Services Washington (Providence) paid $22,960,458, split between federal and state Medicaid, the United States and Washington State. This settlement represents the largest health care fraud settlement to date in the Eastern District of Washington. The whistleblower was the former medical director of neurosurgery for the hospital system, and he will receive $4,197,734 from the settlement.

According to the allegations, the two neurosurgeons employed by the hospital system played with the hospital system’s compensation system by performing more procedures at a higher complexity than was medically necessary. One surgeon worked in the hospital system between 2013 and 2018 and the other only worked in the hospital system between 2015 and 2017. Hospital staff at various times raised concerns about the quality of care of surgeons and to the medical necessity of the procedures. Both surgeons were placed on administrative leave over these concerns and both resigned; however, the hospital system has not reported any surgeons to the National Practitioner Data Bank or the Washington State Department of Health. Additionally, the hospital has neither withheld nor reimbursed Medicare or Medicaid payments for surgeries performed by either physician.

The hospital billed various government programs, including Washington State Medicaid, Medicare, TRICARE, VA Community Care and FEHBP, for surgeries performed by the two neurosurgeons in question.

Not only coding for more intense procedures than necessary, but also actually performing those procedures is a nightmare for patients and taxpayers. One of the surgeons was in the 90th percentile of the hospital’s top neurosurgeons due to the complexity and volume of surgeries performed, earning between $2.5 and $2.9 million a year, and the hospital system n did not see this as an alarm signal. Lacking oversight of quality of care, patient safety, and claims, Providence entered into a Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).

“Patients with back pain and spinal cord injury deserve top-notch care from a provider,” said the U.S. Attorney for the Eastern District of Washington, “who puts the patient first and is not not unduly influenced by the amount he can charge for the procedure.” The U.S. attorney also noted that since the hospital system does not discipline doctors, surgeons could continue this fraudulent scheme at other healthcare facilities. healthcare professionals have the authority to report this type of misconduct in order to protect future patients and the solvency of taxpayer-funded healthcare programs.

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