Mercy Regional Medical Center was recently implicated in a False Claims Act allegation for violating Medicare billing requirements, a Department of Justice investigation revealed Friday.
Catholic Health Initiatives, which used to own Mercy, paid out $7.8 million for violating health guidelines and improper billing to patients. Mercy is now owned by Centura Health, which still has a joint-operating agreement that is part of CHI.
Because the case is still sealed by federal order, the details of Mercy’s violation are unclear.
The original complaint was filed seven years ago by a registered nurse and a Medicare-compliance consultant in Kentucky. The two claimed hospitals were billing Medicare for procedures that did not meet National Coverage Determination (NCD) guidelines.
Bryan Vroon, an Atlanta-based attorney who represented the clients, told The Durango Herald on Monday that there were no “whistleblowers” from Durango. Instead, he knew there were violations based on the codes of Medicare.
“Each hospital is required to submit codes to Medicare, based on what was done with each patient admission,” Vroon said. “We were able to use those codes to determine where there were violations.”
An implantable cardioverter defibrillator (ICD) is implanted near the heart, and delivers a shock to restore the heart’s normal rhythm when the device detects life-threatening pulsations. The NCD mandates that ICDs should not be implanted in patients who suffered a heart attack or had heart bypass surgery.
“The medical purpose of a waiting period – 40 days for a heart attack and 90 days for bypass/angioplasty – is to give the heart an opportunity to improve function on its own to the point that an ICD may not be necessary,” the DOJ said in a news release. “The DOJ alleged that from 2003 to 2010, each of the settling hospitals implanted ICDs during the periods prohibited by the NCD.”
Vroon said the DOJ investigation has led to a 28 percent reduction in ICD procedures, saving the Medicare program $2 billing during the last five years, and ensuring patients “receive needed treatment based on science.”
In total, almost 500 hospitals paid $250 million to resolve the complaint filed under the False Claims Act, which permits individuals to bring a lawsuit on behalf of the Medicare program.
“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,” Deputy Assistant Attorney General Benjamin C. Mizer said in the DOJ’s release.
“We are confidant that the settlements announced (Friday) will lead to increased compliance and result in significant savings to the program while protecting patient health.”
When asked for comment, officials at Mercy referred The Durango Herald to a prepared statement from CHI that said the company is thankful its patients have received their treatment and have not been financially impacted.
“Along with hundreds of other hospitals across the country, Catholic Health Initiatives has been working with the government in connection with its inquiry into whether certain procedures involving implantable cardioverter defibrillators met Medicare reimbursement criteria,” the release, provided by National Media Relations Director Michael Romano, said.
“While the government’s focus was on the billing criteria, our primary focus has always been to ensure that our patients are provided with appropriate care, and we are satisfied that appropriate care was, in fact, provided to our patients.”