Prime Healthcare Services has blasted the U.S. Justice Department for using a whistle-blower lawsuit to challenge physician judgment over hospital admissions and called for the $50 million complaint to be thrown out.
The DOJ alleged in June that the Ontario, Calif.-based health system had a “culture” that pressures its physicians to admit Medicare beneficiaries to 14 of its hospitals for inpatient stays when they should be on shorter outpatient observation visits, and those billings are false Medicare claims.
Prime said the CMS' standards for inpatient and outpatient admissions were “confusing” and “subjective,” and the chain alleged the agency and DOJ improperly questioned physicians' subjective judgment on patient treatment in their quest to join a $50 million False Claims Act suit against the hospital chain.
Karin Berntsen, former director of improvement at Alvarado Hospital in San Diego, filed the initial whistle-blower complaint back in 2011, alleging that hospital alone raked in an extra $4 million from Medicare thanks to those inpatient stays. Berntsen claimed the rest of Prime's hospitals had similar issues.
But Prime says the feds never tied those allegations to specific improper admissions and contends the treatment was medically necessary.
CMS criteria states physicians should admit beneficiaries for inpatient treatment if they need more than 24 hours of care, whereas outpatient observation stays should be used for treatment that will last less than 48 hours. It's up to physicians to determine which type of admission is appropriate and have documentation to prove their rationale.