“Over-Operated” – Whistleblower Receives Over $4.1 Million for Reporting Medically Unnecessary Neurosurgery Procedures Fraudulently Billed to Federal Healthcare Programs

April 14, 2022.  The US Division of Justice settled a case towards a healthcare and hospital system for performing medically pointless neurological surgical procedures and billing federal healthcare applications for them.  Under the terms of the settlement, Windfall Well being & Providers Washington (Windfall) paid $22,960,458, divided amongst federal and state Medicaid, the US, and the State of Washington.  This settlement represents the most important healthcare fraud settlement to date within the Japanese District of Washington.  The whistleblower was the previous Medical Director of Neurosurgery within the hospital system, and they’ll obtain $4,197,734 of the settlement.

In accordance to the allegations, the 2 neurosurgeons employed by the hospital system gamed the hospital system’s compensation system by performing extra procedures at larger complexity than had been medically mandatory.  One surgeon labored on the hospital system between 2013-2018 and the opposite solely labored on the hospital system between 2015 and 2017.  Hospital employees at varied factors raised considerations about each surgeons’ high quality of care and procedures’ medical necessity.  Each of the surgeons had been positioned on administrative depart due to these considerations and each resigned; nevertheless, the hospital system didn’t report both surgeon to the Nationwide Practitioner Information Financial institution or the Washington State Division of Well being.  Furthermore, the hospital didn’t refuse or refund any Medicare or Medicaid funds for surgical procedures carried out by both doctor.

The hospital billed a wide range of authorities applications, together with Washington State Medicaid, Medicare, TRICARE, VA Neighborhood Care, and FEHBP, for surgical procedures carried out by the 2 neurosurgeons in query.

Not solely coding for extra intense procedures than mandatory but in addition truly performing mentioned procedures is a nightmare for sufferers and taxpayers.  One of many surgeons was within the ninetieth percentile of prime producing neurosurgeons within the hospital due to the complexity and quantity of surgical procedures carried out, incomes between $2.5-$2.9 million yearly, and the hospital system didn’t understand this as a pink flag.  For lack of oversight on high quality of care, affected person security, and claims, Windfall entered right into a Company Integrity Settlement (CIA) with the U.S. Division of Well being and Human Providers, Workplace of Inspector Common (HHS-OIG).

“Patients with back pain and spinal injury deserve top-notch care from a provider,” mentioned the U.S. Legal professional for the Japanese District of Washington, “who puts the patient first and is not improperly influenced by how much he can bill for the procedure.”  The U.S. Legal professional additionally famous that because the hospital system didn’t self-discipline the physicians, the surgeons may proceed this fraud scheme at different healthcare amenities.  Whistleblowers within the healthcare trade are empowered to report this type of misconduct so as to defend future sufferers and the solvency of taxpayer-funded healthcare applications.

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