US False Claims Act: Did Hospital Manipulate Patient Data In The Emergency Department?

US False Claims Act: Did Hospital Manipulate Patient Data In The Emergency Department?

Legal Eagle Eye Newsletter for the Nursing Profession

August 2017

False or fraudulent claims for payment by the US government are outlawed by the US False Claims Act (FCA), including Medicare and Medicaid reimbursements. One avenue for enforcement of the FCA is a civil lawsuit filed by a private individual on behalf of the US government for repayment of government funds paid out under false or fraudulent premises.

The FCA encourages and rewards citizens who blow the whistle on fraud and abuse by recipients of government payments. The US government must be offered the opportunity to take over control as well as the court costs and other expenses of the private individual’s civil lawsuit. If the government is successful the private individual who started the lawsuit can be awarded a percentage of what is recovered by the government from the contractor liable for fraud. Although the percentage going to the private individual is relatively small, the reward can still be substantial when there is a multi-million dollar recovery. UNITED STATES DISTRICT COURT KANSAS July 7, 2017

An individual who apparently had worked as a nurse in the hospital’s emergency department filed a civil lawsuit against the hospital under the US False Claims Act. The focus of the lawsuit is the fact that the hospital receives enhanced Medicare reimbursements available to hospitals that meet certain quality standards. The quality standard relevant to this case is the time lag between a chest-pain patient’s arrival in the emergency department and the patient’s first EKG.

At this stage the US District Court for the District of Kansas has not conclusively held the hospital liable for false or fraudulent documentation practices intended to enhance Medicare reimbursement. Nevertheless, the Court did rule that the allegations raised against the hospital in this civil case, if they can be proven, would be False Claims Act violations.

The Court applauded the emergency department’s nursing education director for implementing a policy for chest-pain patients to be directed immediately from the front desk to a treatment room and to be given an EKG immediately. However, according to testimony from the plaintiff and other emergency department personnel, the director also instructed the nurses to back-note the clock-time of their first encounter with the patient to coincide with the clock-time of the EKG. That was problematic because the Medicare standard for evaluating promptness of emergency department care looks to the clock-time of the actual first encounter with the patient, which may occur with a front-desk clerk, triage nurse, nursing assistant or other staff member well before the first EKG is actually done. More ominous, it also came to light that the hospital had been removing and destroying documentation from emergency department charts that, if found in an audit, would tend to lengthen the time delay as the Medicare standard defines it. US v. Hospital, 2017 WL 2905406 (D. Kan., July 7, 2017).