News & Views

DOJ Shows Continued Interest in Ferreting Out Inappropriate Inpatient Care

Oftentimes, potential healthcare whistleblowers inquire about whether the Justice Department has an interest in pursuing particular healthcare fraud schemes. The best indicators of DOJ interest are recent False Claims Act qui tam interventions and settlements. Presently, these indicators show that the government is especially interested in qui tam allegations involving hospital inpatient fraud.

The latest example involves the largest False Claims Act recovery in the District of Arizona. In this False Claims Act recovery from Carondelet Health Network, the nonprofit health system agreed to pay $35 million to resolve allegations that two of its hospitals violated the FCA by submitting false claims to government healthcare programs for claims relating to inpatient rehabilitation facility services. Specifically, according to the settlement agreement, these claims for inpatient rehabilitation facility services were not properly reimbursable under applicable coverage criteria because the patients were not appropriate for inpatient rehabilitation facility services.

These allegations were brought to the attention of the government via a False Claims Act qui tam action. According to the initial qui tam complaint, the relator was a Corporate Responsibility Coordinator at Carondelet, who was certified as a Medical Reimbursement Specialist. With this case settling in less than three years, the relator undoubtedly played an important role in marshalling the necessary facts and evidence for the government. The government recognized the relator’s efforts by agreeing to pay a relator’s share of nearly $6 million.

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