Government Action Spurred by Whistleblower Lawsuit
PHOENIX, AZ / ACCESSWIRE / April 12, 2018 / Due to the persistence of a former employee's refusal to accept the routine submission of false Medicare claims by Arizona's largest private employer and one of the nation's largest nonprofit hospital systems, the U.S. Government has recovered $18.7 million (including interest) in taxpayer dollars. The current recovery resolves allegations that Banner Health routinely overcharged Medicare for short-stay inpatient and observation claims.
The case, filed in 2013 in the U.S. District Court for Arizona, is styled United States ex rel. Cecilia Guardiola v. Banner Health and NCMC, Inc., No. 2:13-cv-02443. Attorney Mitch Kreindler of Kreindler & Associates in Houston, Texas and his co-counsel, Edmundo Robaina of Robaina & Kresin PLLC in Phoenix, represented Guardiola, during the legal proceedings The settlement covers a period of nine years, from November 1, 2007 through December 31, 2016. Guardiola estimates that the incorrect claims were filed on behalf of thousands of patients.
The $18,300,000 settlement is among the largest ever in the District of Arizona under the False Claims Act. Suits filed nationwide under the False Claims Act in fiscal year 2017 yielded more than $1.0 billion in recoveries to the federal government, according to statistics maintained by the Department of Justice.
Guardiola is a registered nurse, compliance professional and law school graduate with extensive nursing and compliance experience. She was hired by Banner Health in October 2012 as its Corporate Director, Clinical Documentation. Her role was to improve the quality of medical documentation to support improved billing with the goal of identifying positive revenue for Banner hospitals. The position required Ms. Guardiola to observe and evaluate compliance efforts at multiple Banner hospitals and throughout the Banner Health corporate system. Quickly recognizing that her efforts to bring ethical compliance efforts to Banner were and would continue to be ineffective, Ms. Guardiola resigned her position in December 2012.
Once hired, Ms. Guardiola's first priority was to evaluate Banner's existing clinical documentation program and identify opportunities for improvement. She assessed randomly chosen medical records to develop baseline measurements from which to evaluate the quality of existing medical documentation efforts. Upon completing her assessment, Ms. Guardiola identified many ways in which Banner could improve its revenue streams.
When senior Banner administrators repeatedly expressed concerns that Banner was failing to capture inpatient stays properly, Ms. Guardiola expanded her evaluation to include short-stay inpatient claims, an effort which led her to uncover Banner's wrongdoing. Ms. Guardiola discovered that all Banner hospitals were billing an inordinate and improper number of short-stay claims, particularly those for expensive cardiac procedures. In her complaint, Ms. Guardiola identified over 650 instances where Banner billed Medicare for an inpatient claim, even though the patient was admitted to and discharged from the hospital on the same calendar day.
Ms. Guardiola discovered that two Banner hospitals, Boswell and Del Webb, intentionally falsified documentation to ensure payment of fraudulent claims. She found that they devised a means of circumventing the Medicare Administrative Contractor's (MAC's) review process by mischaracterizing certain claims for cardiac procedures (such as implantable defibrillators, pacemakers and stents) as "urgent" on Medicare claim forms when the claims should have been characterized as "elective," which is what was done by all of Banner's other hospitals. By labeling the claims as "urgent," Boswell and Del Webb were able to prevent a large number of financially lucrative claims from being denied.
Ms. Guardiola also found that Banner systematically inflated the number of hours for which patients received outpatient observation care. Because Medicare reimburses such care on a per-hour basis, the inflated figures caused Banner to receive payments higher than it was entitled to claim.
When she raised her concerns with Banner administrators, she was met with resistance to change and an undue emphasis on revenue enhancement through inpatient admissions. Compliance was treated as an afterthought. "Banner provides quality healthcare to many residents of Arizona and other states, and I wanted them to focus on the long-term benefits of acting with integrity. But they were unwilling to do that," said Guardiola.
"Thanks to Ms. Guardiola's honesty and courage, taxpayers have been reimbursed for the misconduct alleged in her Complaint," Guardiola's attorney, Mitch Kreindler said. "Ms. Guardiola recognized the wrongdoing and called it to the attention of Banner's most senior management. She pursued the fight for what she knew was right." Said Guardiola, "I can only hope that this settlement is the 'change agent' that allows Banner to bring its focus back to where it belongs."
"While Banner will likely try to downplay these allegations as 'technical billing issues,' the fact is that Ms. Guardiola encountered resistance to fixing systemic problems that caused the billings to regularly recur," said Kreindler. He added, "Everyone knows the difference between right and wrong. But it takes a person of integrity, like Ms. Guardiola, to stand up and say, 'I'm not going to allow this to happen.' She is the true hero in this story."
Guardiola's case was formally filed on November 27, 2013 under the False Claims Act and its qui tam provisions. The law allows any person with evidence of fraud against federal programs or contracts to sue the wrongdoer on behalf of the government. The Act provides for the whistleblower, or relator, to receive between 15 and 30 percent of the amount recovered by the government. Under this provision, the federal government will pay 18% of its recovery to Guardiola for her assistance.
Kreindler & Associates was founded in November 2000 and is dedicated almost exclusively to the representation of whistleblowers under the False Claims Act and other whistleblower statues. The firm provides an uncommon degree of client service and support to whistleblowers that have made the difficult decision to do what is right, often at significant personal hardship. With a practice that is national in scope, Kreindler's offices are located in Houston and Philadelphia areas.
For more information about Kreindler & Associates and the whistleblower provisions of the False Claims Act, visit www.blowthewhistle.com or call (713) 647-8888.
CONTACT: Mitch Kreindler | 713-647-8888 | [email protected]
Note to media: Copies of the complaint, settlement agreement and other materials are available upon request
SOURCE: Kreindler & Associates.