Neurosurgeons employed by UPMC allegedly submitted claims for assisting with or supervising surgical procedures performed by others when those clinicians did not participate in the surgeries to the degree required.
The University of Pittsburgh Medical Center, the University of Pittsburgh Physicians, UPMC Community Medicine, Inc., and Tri-State Neurosurgical Associates-UPMC, Inc. will pay $2.5 million to settle False Claims Act allegations, the Department of Justice said this week.
U.S. Attorney David J. Hickton said the settlement resolves several of the allegations in a whistleblower lawsuit filed in federal court in Pittsburgh. The settled claims contended that UPMC violated the False Claims Act by submitting false claims for payment to the Medicare program.
Specifically, neurosurgeons employed by UPMC allegedly submitted claims for assisting with or supervising surgical procedures performed by other surgeons, residents, fellows, or physician assistants, when those neurosurgeons did not participate in the surgeries to the degree required.
"Today's settlement demonstrates our commitment to protecting federal health care programs from fraud," Hickton said. "By pursuing False Claims Act cases like this, we send a clear message that healthcare providers must follow the rules when they deal with federal healthcare programs, and that this office will hold accountable those who do not."
Hickton said the settlement also resolves allegations that one neurosurgeon submitted claims to Medicare for spinal decompressions that were not performed. Several claims in the whistleblower suit were not resolved in the DOJ settlement, and the whistleblowers will continue to independently pursue those claims.
In a statement provided Thursday, UPMC said:
"The settlement announced today wraps up the government's investigation of billing submitted to Medicare, Medicaid and TRICARE by three UPMC-affiliated entities for professional services. UPMC learned that some of the billing these entities submitted did not accurately reflect the services performed, and resulted in more reimbursement than was due. The physicians themselves did not submit these bills.
UPMC discovered the billing discrepancies, disclosed the errors to the United States Attorney's office, conducted an internal review, and fully cooperated with the government's review. UPMC took steps to strengthen the processes and practices in the billing systems that had allowed incorrect billing. Under the settlement, UPMC admits no liability.
While the settlement also includes some of the allegations raised by three former UPMC employees, who filed a whistleblower (or qui tam) lawsuit under the Federal Civil False Claims Act, the government, after an extensive investigation, declined to intervene in or take up the vast majority of those allegations.
Given that the government has declined to intervene, if the whistleblowers choose to pursue their lawsuit without the government, UPMC will defend the matter vigorously."