Multi-Hospital Not-for-Profit System

Consulting Expert - Medicare Fraud and Abuse

The heart hospital of a regional multi-hospital system was under government investigation stemming from a qui tam action alleging violations of the anti-kickback statute.  The cardiologists on staff were being scheduled time at the diagnostic unit (heart station) based on case volume admitted to the hospital.  HMP was asked to review the available information to assess any trends or patterns and advise the hospital and counsel in the course of the litigation and provide expert testimony as needed.

Issues

• The relator was a former cardiologist who had been terminated by the group.
• The perception of wrongdoing was high because for a long period access to the heart station was mathematically based on the invasive cardiology volume referred to the hospital by individual cardiologists or their group practice.
• Basing coverage of the heart station on volume is not unusual because this assigns the work to the physicians that are most likely to be in the hospital.
• Did the assignment to the heart station actually change any cardiologist’s hospital referral patterns?

Approach

• HMP obtained a database of admissions for the years in question.
• Using its extensive data mining capabilities, HMP was able to evaluate competitor patterns, compare alternate methods of allocating time at the diagnostic unit, and review the more than 86,000 individual claims for certain criteria that should have excluded them from the investigation.

Result