West Chester Hospital in Cincinnati and its parent company UC Health will pay $4.1 million to settle allegations that the hospital billed Medicare and Medicaid for medically unnecessary spine surgeries.
The settlement reflects a yearslong, growing trend of the government pursuing cases that allege unnecessary procedures, legal experts say.
UC Health said in a statement Friday that it denies the government's allegations and settled to avoid uncertainty and the expense of litigation.
“We have agreed to refund certain payments under Medicare and Medicaid in connection with procedures performed by a surgeon at West Chester Hospital,” according to the statement. “The surgeon was not an employee of UC Health or West Chester Hospital but had privileges at West Chester Hospital for a time.”
UC Health had operating revenue of $1.3 billion in 2014, according to the Modern Healthcare financial database.
The government alleged that a surgeon with admitting privileges to the hospital, Dr. Abubakar Atiq Durrani, performed medically unnecessary spine surgeries between 2009 and 2013. The hospital then knowingly submitted claims to Medicare and Medicaid for hospital charges related to the medically unnecessary surgeries.
Durrani was arrested in July 2013 and charged with healthcare fraud violations, but he fled the country after his arraignment and remains a fugitive, according to the U.S. Justice Department.
Marc Raspanti, a partner at Pietragallo Gordon Alfano Bosick and Raspanti, said cases involving unnecessary surgeries are a growing focus for the Justice Department.
“This has been a concern of the Department of Justice for some time,” Raspanti wrote in an e-mail. “I predict many more of these cases in the future.”
And provider organizations such as hospitals, clinics, ambulatory surgical centers and physician offices, have long been the targets of these cases.
Jennifer Weaver, a partner at Waller Lansden Dortch and Davis, also said the number of such cases aimed at provider organizations is likely to rise. In the past year or two, the Justice Department has also more frequently been going after the individuals involved.
“In the past, the cases were brought against hospitals,” Weaver said. “You were leaving potential liability on the table in cases that could be brought against individual physicians. I think there's more of a push these day to go after any of these parties that could be held legally responsible for False Claims violations.”
She noted that cases alleging unnecessary surgeries can be tough ones for providers.
“In my view, if reasonable minds can differ and reasonable medical judgments can be made on either side, that should preclude a claim from being false,” Weaver said. “This is not an area that is black and white. There's a lot of gray involved and sometimes the government doesn't appreciate that.”
She acknowledged that there are cases where bad actors bill for services they don't actually render.
In May, a Michigan physician, Dr. Aria Sabit, admitted that his involvement with a physician-owned distributorship led him to compromise his medical judgement and harm patients by performing medically unnecessary surgeries. In July, a Detroit-area doctor was sentenced to 45 years in prison for giving more than 500 patients unnecessary chemotherapy in order to bill private insurance companies and Medicare.
Weaver, however, said such cases are outliers. She said the government is now also going after providers who may be performing more of a certain type of procedure than other doctors. “Maybe a provider is performing more procedures than a peer, but that in and of itself doesn't mean that provider is intentionally defrauding the government."
To be found liable in False Claims Act cases, a provider has to be shown to have either known a claim was false or acted with reckless disregard or deliberate ignorance.
Christina Kuta, an associate at Roetzel and Andress, said the West Chester case is a bit unusual in that the accused doctor fled the country.
“You don't typically see a physician trying to dodge or circumvent those charges,” Kuta said. “Usually, you see them trying to defend themselves, particularly if they don't think they did anything wrong.”
The allegations stem from a whistle-blower complaint filed by former patients of Durrani, and they will receive about $805,000 from the settlement.