Investor-owned hospital chain HCA was hit with a whistleblower lawsuit accusing it of cheating the federal government out of millions of dollars through inflated or fraudulent billing through its rehabilitation hospitals.
In a False Claims Act complaint unsealed Tuesday, a former HCA occupational therapist alleged the health system submitted false claims from its rehabilitation network across 18 states to secure higher reimbursement rates from the Inpatient Rehabilitation Facility Prospective Payment System than it could obtain from the Inpatient Prospective Payment System.
Inpatient rehabilitation hospitals can be paid higher rates when 60% of its patients fall under "qualifying admissions," meaning patients who have higher-acuity diagnoses that generally fall within one of 13 conditions like myopathy, a disease in which the muscle fibers do not function properly.
The government declined to intervene in Clarisse Christine Toledo's lawsuit. The former HCA employee and licensed occupational therapist initially filed her complaint in December 2017 in Washington, D.C., federal court. Toledo voluntarily dismissed her False Claims Act allegations, but the federal government can revive those claims.
"We were not aware of these claims before the federal government decided not to participate and the court dismissed them," HCA's spokeswoman Harlow Sumerford said in an email on Thursday. "We have robust processes and oversight of our rehabilitation services."
The Justice Department will review court orders and notices of appeal as well as any potential dismissal or settlement.
Toledo still alleges that HCA and Bayshore Medical Center retaliated against her by firing her.
Therapists allegedly left patients unsupervised in "group therapy" sessions while doing documentation, but then recorded this unsupervised time as therapy and billed accordingly, Toledo claimed.
Also, staff were not trained to enter information required for the Inpatient Rehabilitation Facility Patient Assessment Instrument and would make up information, according to the lawsuit. Staff would also allegedly submit claims for unnecessary care, fake diagnoses, more direct therapy time than what was administered, and claims with missing or backdated physician orders.
During one training session for HCA's Gulf Coast division, a clinical director allegedly instructed staff to rely on physical symptoms rather than diagnostic tests when sending patients who had symptoms of myopathy to physicians, Toledo said.
That was one of several alleged tactics that would inflate the number of myopathy claims to meet the 60% rule, she said. Some patients were also admitted to HCA rehabilitation facilities on a "trial basis" with the intent to improve compliance with the 60% rule, even though the CMS states that trial admissions are not reasonable or necessary medical treatment, according to the complaint.
Toledo recorded one situation where her supervisor at Pasadena, Texas-based Bayshore Medical Center's rehabilitation hospital allegedly instructed her to use backdated physician admission orders "to cover (Bayshore), because technically, (Bayshore) shouldn't have been doing any treatment on those patients whatsoever," and because Bayshore had "to do something to cover ourselves."
In another instance, Toledo allegedly was asked to change assessment instrument codes for a patient who had been discharged several months prior. She allegedly called the software manufacturer for guidance, who told Toledo that this wasn't permissible under CMS rules and was reprimanded after relaying that conversation to her supervisor. Toledo said she was ultimately fired after a subsequent situation where she was asked to change patient diagnosis codes to comply with the "60% rule," according to the complaint.
Toledo said she kept a log of all the corrections she had made to prevent the alleged fraud.
HCA is also facing another False Claims Act suit in California federal court that includes similar allegations. In that lawsuit first filed in 2017, a former HCA nurse claimed that administrators billed intensive-care unit, medical-surgical and telemetry services on an inpatient basis when the patient was still in the emergency department.
