This week, a federal lawsuit filed qui tam by some former Vanderbilt University Medical Center doctors allege that the renowned hospital has been engaging in a vast conspiracy to defraud Medicare for years.
You can read the 71-page PDF of the complaint (attached at the end of the post) if you are especially interested in the sausage, but here's the nuts from my NashvillePost report from yesterday morning:
Under federal law, hospitals are only permitted to bill Medicare and state insurance programs for "teaching physician services" if the teaching physician is present during the key portion of the procedure — and for surgeries, the law requires the teaching doctor be present during "all critical portions" and "immediately available to furnish services during the entire procedure."
The plaintiffs allege that Vanderbilt's "scheduling and staffing policies force surgeons to routinely overbook their schedules and rely on residents to perform the critical portions."
The suit goes on to claim that, oftentimes, surgeons were booked for multiple procedures simultaneously, often in geographically disparate parts of the hospital. However, according to the suit, Vanderbilt bills these procedures as having satisfied Medicare's requirements and, after a 2008 internal audit exposed the billing practice, VUMC designed, created and implemented a proprietary electronic record system which produces documentation to support the alleged false claims.
"Vanderbilt's electronic record keeping system lists back-up surgeons who are purportedly available to cover the procedures of attending surgeons during times when those surgeons have more than one ongoing operation," the suit reads. "However, those covering surgeons are not actually responsible for those surgeries. Indeed, they are never in the operating suite and are frequently not even in the hospital during their scheduled coverage."
Further, the doctors claim, Vanderbilt routinely — "nearly 100 percent of the time," according to the filing — submits false claims for so-called "medically directed" anesthesia despite not meeting the stringent federally mandated criteria.
"Vanderbilt trains and encourages residents to prepare false post-treatment records which indicate the presence of an attending physician ICUs, when in fact such physicians are not present," according to an oft-repeated allegation in the 71-page complaint.
The suit also claims that doctors who raise questions about the practice, including those who filed the suit, are "simply dismissed or removed."
VUMC vociferously denies the allegations, saying that such a scheme would require "thousands of individuals" to execute. The whistleblowers say that VUMC's much-lauded VPIMS electronic-record keeping system helps to perpetuate the alleged deception, for example: by allowing doctors to check-in as present for surgeries remotely.
Under the False Claims Act, the federal government can intervene and prosecute these types of cases after they are filed by whistleblowers. While they decide, the case remains sealed (this suit was filed in early 2011). In this instance, the Department of Justice requested five extensions to the deadline to decide whether to intervene. A judge denied the fifth motion, unsealing the complaint, though the feds say they will continue their investigation and reserve the right to intervene later.
VUMC said they are and have been aware of the investigation.
One of the most disturbing allegations is this one:
[One doctor] alleges that he was summoned to an operating room to discover an unsupervised student nurse anesthetist treating a sedated patient undergoing open-brain surgery.
"The attending physician was nowhere to be found, and the patient appeared to be cyanotic and increasingly bradycardic as a result of inappropriate airway management," the lawsuit says.
The attending physician was, apparently, in his office in "an entirely different building."