(Updated Feb. 25)
A former HCA nurse accused the hospital chain of fraudulently billing the federal government for services delivered at Regional Medical Center in San Jose to inflate reimbursement.
In an unsealed False Claims Act case in California federal court, the whistle-blower claimed that Regional Medical Center administrators billed intensive care unit, medical-surgical and telemetry services on an inpatient basis when the patient was still in the emergency department.
It stems from a capacity and understaffing issue, former Regional Medical Center emergency room nurse Zuri Lazard contends. Regional Medical Center is taking on more patients than it can accommodate and hasn't adequately trained its ER nurses in those specialties, which compromises patient care, according to the complaint filed in 2017.
The billing practice allegedly extends beyond the San Jose hospital to other HCA facilities, according to the lawsuit seeking an unspecified amount of damages.
The federal government and California declined to intervene. HCA said in a statement that the allegations are without merit and it is pleased that the state and federal government did not participate in the case.
Emergency medicine is an area where there are lots of opportunities to second-guess and challenge the coding after the fact, said Mark Silberman, a partner at the law firm Benesch.
"The core question is what was the motivation," he said. "Was it for the best interest of the patients or to obtain profits they weren't entitled to?"
Lazard claims that Regional Medical Center's emergency room typically has twice as many patients as beds. Management allegedly requires staff to tell other facilities that there is room for additional patients even when there isn't, which is "done solely to increase billing," the lawsuit claims.
She alleges that "holds" waiting for an inpatient bed to open up can spend days in the ER, although the documents allegedly claim they were elsewhere. Some of these "holds" were allegedly only treated by ER staff, but the charts indicate that ICU, medsurge or telemetry staff provided the services in inpatient beds that do not exist, boosting reimbursement, according to the complaint.
"The patients in the ER rooms lay on hard gurneys," the lawsuit reads. "Sometimes, rather than be in an ER enclosure, they are merely stuck on these gurneys in hallways for the entirety of their stay—days upon days. The ER nurses are unable to turn the patients every two hours as needed and/or pad and elevate the patients' bony prominences to help prevent the patients from developing bedsores."
The ER allegedly lacks basic supplies, a robust supply of food, ventilated acquired pneumonia kits, an adequate supply of tube feeding pumps or a centralized monitoring station, according to the lawsuit. Regional Medical Center is also allegedly placing overflow "hold" patients in unsafe areas, including an old electrophysiology lab that does not include a handicap-accessible bathroom, among other issues listed in the complaint.
Claims processors have no way of sorting through the electronic charting system to verify whether the patient was in the emergency department or an inpatient bed, Lazard alleges.
When Lazard told management that emergency room nurses aren't equipped to provide remote monitoring and other specialized services, the ER director wrote in an email, "it is within your scope of practice to perform admission assessments of patients while they await an inpatient bed," according to the lawsuit.
Lazard also accused Regional Medical Center of directing its staff to inflate its acuity scores and revenue codes that denote more care was provided, increasing reimbursement. In addition, administrators were allegedly billing the government for care delivered in a private room even when they housed multiple patients.
When Lazard raised these concerns with her supervisors, she was allegedly threatened with termination, escorted off the premises and had her wages and hours cut, among other retaliatory actions listed in the complaint.