Our glorious Sunshine State is known for many things, most of which are wonderful. They include hundreds of miles of sandy beaches, world famous theme parks and incomparable citrus fruits. There are, of course, a few Floridian facts that aren’t so lovely. Hurricane season is an example. The unfortunate presence of health care fraud is another.
By no means is the latter an issue that is exclusive to Florida. However, our famed University of Miami (UM) isn’t doing the state any favors by having gotten itself involved in some fraudulent activity as of late. As reported by the United States Department of Justice earlier this week, UM has agreed to pay $22 million to settle claims that it was involved in medically unnecessary laboratory tests and fraudulent billing practices. The university allegedly engaged in three practices that violated the False Claims Act.
Allegation one involves improper billing.
According to court documents, the first was that UM knowingly engaged in improper billing relating to its off campus Hospital Facilities. Medicare allows for physician offices to be converted into Hospital Facilities if certain requirements are met. However, these facilities must inform beneficiaries of the higher costs involved in visiting them.
The United States contends that UM converted numerous physician offices to Hospital Facilities in order to seek higher payments. They also did so without providing Medicare beneficiaries the required notice.
Allegation two involves unnecessary lab tests.
The second allegation is that UM billed federal health care programs for medically unnecessary laboratory tests. These were for patients who received kidney transplants at the Miami Transplant Institute (MTI).
“Each time a patient checked into the MTI, UM’s electronic ordering system triggered a pre-set ‘protocol’ of tests to be run for the patient at UM’s laboratory,” reports the DoJ, “The government alleged that several tests on the protocol for all kidney transplant patients were medically unnecessary and dictated by financial considerations rather than patient care.”
Allegation three involves false claims.
Thirdly, the government alleges that UM caused Jackson Memorial Hospital (JMH) to submit inflated claims for reimbursement. These were for pre-transplant laboratory testing which was conducted at the MTI in violation of related party regulations. By doing so, UM limited the reimbursement a provider could obtain for tests performed by a related entity to that entity’s actual costs.
According to the DoJ report, “the government alleged that UM did so by controlling JMH’s decision to purchase pre-transplant laboratory tests from UM at inflated rates in exchange for UM’s surgeons and Department of Surgery continuing to perform surgeries at JMH. In a separate agreement, the United States has reached a $1.1 million settlement with JMH relating to this conduct.”
The $22 million settlement resolves allegations made in the three lawsuits.
They were filed under the qui tam, or whistleblower, provisions of the False Claims Act. The act permits private individuals to sue on behalf of the government for false claims and to share in any recovery. The DoJ makes sure to note that the claims settled by this agreement are allegations only. There has been no determination of liability.
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