Emory will pay $2.4 million to the Department of Justice (DOJ) after a government review in late October found that Emory University Hospital, Emory University Hospital Midtown and 500 other health care providers had improperly billed Medicare for certain surgical procedures.
Seven years ago, two Medicare-compliance and reimbursement consultants filed a complaint against the hospitals, spurring the DOJ’s investigation. In it, Leatrice Richards and Thomas Schuhmann listed hundreds of hospitals that were billing Medicare for surgeries to implant cardioverter-defibrillators (ICDs), a device which delivers a shock to a patient’s heart to restore normal rhythm.
However, Medicare does not generally cover ICD procedures for patients who have undergone coronary bypass surgery or angioplasty within the last 90 days or have experienced a heart attack within the last 40 day. The DOJ’s investigation found that some hospitals, including the two from Emory, were not following Medicare’s rules requiring a waiting period before implanting the device, which costs about $25,000.
Since the beginning of the investigation, ICD procedures in Medicare patients have decreased by an estimated 28 percent, which equates to savings of more than $2 billion for the Medicare Program over the last five years.
U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida called this case “one of the nation’s largest whistle-blower lawsuits” in an Oct. 30 Atlanta Journal-Constitution article. Whisteblowers Richards and Schuhmann received over $38 million dollars from the total $250 million settlement.
Since receiving notification of the investigation in 2010, Emory has cooperated fully with the DOJ, according to a statement from the University. Emory completed a voluntary review of approximately 230 ICD claims, policies and procedures, and worked with the government to reach a settlement, the statement said.
Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division said in a Oct. 30 DOJ press release that the DOJ’s investigation will hold hospitals and health care providers accountable for performing procedures that fail to comply with Medicare billing rules. According to him, Emory’s and other hospitals’ settlements will be a positive change to the Medicare program.
“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,” he said.