This is the third time that the nurse has brought a successful whistleblower lawsuit against a hospital system where she has worked.
Banner Health, a Phoenix-based health system that owns 28 hospitals across six states, agreed to pay over $18 million to settle allegations that 12 of its hospitals in Arizona and Colorado knowingly submitted false claims to Medicare by admitting patients who could have been treated on a less costly outpatient basis.
Cecilia Guardiola, Banner’s former corporate director of clinical documentation, brought this suit under the federal False Claims Act (FCA), a law that allows private party whistleblowers to report fraud against the government and receive a piece (15 percent to 30 percent) of the recovery as an award. Under the FCA, the government has the option to join the lawsuit and sue an alleged fraudster alongside the whistleblower, as it did in this case. Guardiola worked at Banner Health for less than three months and will receive a whistleblower reward of approximately $3.3 million.
Generally, Medicare compensates healthcare providers significantly less for outpatient services than inpatient services. Per Medicare program rules, a patient’s physician must decide if a patient needs hospital care for 24 hours or more, and if that’s not the case, a patient should not be admitted to the hospital. There is also a third status that falls between inpatient and outpatient called “outpatient observation status.” Observation status is assigned to patients who require a significant amount of treatment or monitoring before a decision can be made about their admission or discharge, for example, following a surgery.
According to the whistleblower’s allegations, Banner Health billed short-stay outpatient services as if they were expensive inpatient services and inflated the number of hours for which patients received outpatient observation care. Guardiola’s complaint specifies more than 700 instances of alleged fraud.
Guardiola was hired in October 2012 to improve Banner’s documentation practices. At the time, Banner believed that missing codes were costing it millions in revenue. Guardiola uncovered many instances where mis-documentation was costing Banner significant amounts of revenue, but upon her review of short-stay inpatient claims, she discovered the alleged fraud. According to the complaint, Guardiola reported the wrongdoing to several members of Banner’s senior management, but it fell on deaf ears. Guardiola left Banner Health only a few months later, and her whistleblower lawsuit was filed within a year of her departure.
In addition to paying $18.3 million, Banner Health agreed as part of the settlement to a Corporate Integrity Agreement (CIA) with the Department of Health and Human Services Office of Inspector General. The CIA requires the company to engage in significant compliance efforts over the next five years, including retaining an independent review organization to review the accuracy of the company’s claims for all services provided to federally funded healthcare programs.
This is the third time Guardiola has brought a successful whistleblower lawsuit against a hospital system where she has worked. In 2016, she successfully sued Renown Health in Nevada for similar practices and helped the government achieve a $9.5 million settlement. In 2012, as a result of Guardiola’s lawsuit, the federal government achieved a $5.1 million settlement with Christus Spohn Health System. For her role in exposing the alleged frauds at these three health systems, Guardiola has received over $6 million in whistleblower awards.
On April 2, my 92-year-old father sustained a fall in his assisted living facility (ALF), which resulted in an emergency department evaluation. Fortunately, he hadn’t
The Centers for Medicare & Medicaid Services (CMS) just issued the above proposed rule—Managed Care Access, Finance and Quality. Before digging into the rule, I
Please log in to your account to comment on this article.
Dr. Ronald Hirsch provides tried-and-true strategies and insight into outpatient in hospital bed stays including determining the applicable definition, who uses it, and when and how to bill for this circumstance, solidified with concrete case examples and expert insight.
Practical solutions for CDM departments to protect your hospital’s revenue.
This webcast teaches hospitals how to comply with CMS price transparency rules and compare their rates with peer hospitals. It covers creating a compliant machine-readable file, comparing negotiated rates, and improving pricing decisions.
The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.
This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.
Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.
Do you struggle with selecting and appending the correct modifier for your medical claims? Join our must-attend webinar, “Mastering Modifier Usage: Preventing Denials and Ensuring Compliance” to reduce claim denials and improve your reimbursement rates.
Kay Piper reviews the guidance and updates coders and CDISs on important information in the AHA’s fourth quarter 2023 ICD-10-CM/PCS Quarterly Coding Clinic in an easy to access on-demand webcast.
Copyright © 2023 ICD10monitor. Powered by MedLearn Media.
