Whistleblower fraud cases help U.S. recover $115 million from Adventist Healthcare

posted on:
September 23, 2015

author:
Archie Grubb

Adventist Healthcare, an Altamonte Springs, Fla.-based hospital network with a long rap sheet and history of fraud settlements, has just agreed to pay the U.S. $115 million to settle allegations stemming from yet more whistleblower complaints.

The U.S. Justice Department said Monday the giant settlement resolves accusations that Adventist paid physicians illegal incentives for referrals and that it modified certain billing codes to get reimbursements from Medicare and Medicaid that were higher than Adventist was entitled to receive.

Whistleblowers Michael Payne, Melissa Church and Gloria Pryor, who worked at Adventist’s Park Ridge hospital in Hendersonville, N.C., and Sherry Dorsey, who worked at Adventist’s corporate office, filed two separate complaints against Adventist under the False Claims Act, which allows private individuals to sue on behalf of the federal government, which investigated the claims and chose to back the complaint.

According to the Justice Department, Adventist submitted false claims to Medicare and Medicaid for services its physicians provided to beneficiaries because those physicians received bonuses calculated based on the value of their referrals to Medicare and Medicaid. Federal law prohibits hospitals from engaging in such financial relationships because they put profits over the medical needs of the patient.

The settlement also resolves allegations that Adventist submitted bills to Medicare for treatments that contained improper coding modifiers that boosted the reimbursement rate.

Acting U.S. Attorney Jill Westmoreland Rose of the Western District of North Carolina, who helped prosecute the case, said that Adventist’s illegal financial arrangements with physicians “undermine patients’ medical care.”

“Patients are entitled to be sure that the care they receive is based on their actual medical needs rather than the financial interests of their physician,” added Assistant Attorney General Benjamin Mizer, head of the Justice Department’s Civil Division.

Whistleblowers whose False Claims Acts complaints lead to financial recoveries for federal agencies and programs are paid between 15 and 30 percent of the total recovery as an award for the important anti-fraud role they pay.  The amount the whistleblowers will receive in this case has not yet been determined, but under law they are entitled to share a very minimum of $17.5 million.

For more information about whisleblower laws and protections, contact an attorney in the Beasley Allen Consumer Fraud Section. Your inquiry is confidential. Contact Archie Grubb, Andrew Brashier, Larry Golston or Lance Gould.

Source: U.S. Department of Justice

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