I was really disappointed to hear about some very serious allegations against the hospital associated with my undergraduate alma mater, Vanderbilt University. I am a lawyer who represents whistleblowers, and I hate to think that such a fine place as Vanderbilt would be engaged in Medicare fraud. However, according to three whistleblowers who filed a qui tam lawsuit against Vanderbilt University Medical Center, the hospital has been systematically overcharging Medicare for ten years.
According to an article in the Nashville Post, Whistleblower Docs Allege Vast VUMC Medicare Billing Deception, the False Claims Act lawsuit was filed by three anesthesiologists who once worked at Vanderbilt. They say that the hospital billed Medicare and Medicaid for "teaching physician services", when in fact the teaching physician was not present during the key parts of the procedure. Under Medicare rules about surgical charges, a hospital is only allowed to charge for a "teaching physician" who is present during "all critical portions" of the surgery, and who is available "during the entire procedure."
According to the whistleblowers, Vanderbilt set policies that "force[d] surgeons to routinely overbook their schedules and rely on residents to perform the critical portions." The situation was so bad that "surgeons were booked for multiple procedures simultaneously" in different parts of the hospital.
Yikes! I know I wouldn't want my surgeon to go AWOL while I was lying on the operating table. According to the three relators (the legal term for whistleblowers who bring a suit under the False Claims Act), however, that is exactly what happened and it led to some pretty frightening situations.
One of the anesthesiologists says he was called into a surgery that supposedly was being supervised by a physician. When he got there, he found a student nurse anesthetist was trying to single-handedly perform the anesthesia for a patient who was in the middle of brain surgery. The patient was struggling to breathe, having become bradycardic and cyanotic (blue). The whistleblower discovered that the allegedly "supervising" physician was in his office, which was in an entirely different building.
Vanderbilt claims the allegations are false, and that it would have taken a coordinated effort by "thousands of individuals" to maintain this much fraud. But the doctors say Vanderbilt managed it via a computer system. After a 2008 audit, they claim Vanderbilt took its overbilling "underground" by writing its very own computer program that automatically generated all the documentation it would need to support the false claims it was making to Medicare.
Since a qui tam suit alleges that the Government has been ripped off, the Government has the right to intervene (take over) in a lawsuit. Here, the Government got five extensions of the time it had to decide whether to intervene, but apparently had not completed its investigation when the judge denied the Government a sixth extension and unsealed the case. In pleadings filed in the case, the Government said that it was not prepared to intervene in the case, but emphasized that it was still investigating the allegations. The Government made it clear that the fact that it was not intervening immediately did not mean that it had decided it was not going to intervene (known as "declining" to intervene). As a whistleblower lawyer, I read those statements as saying that the Government is taking the allegations very seriously and believes there is some evidence of fraud.