BRATTLEBORO — Brattleboro Memorial Hospital paid $1,655,000 to the United States and the state of Vermont to resolve civil claims that it "knowingly" presented or caused to be presented "false claims for payment to Medicare and Medicaid."
According to the U.S. Attorney's Office for the District of Vermont, from approximately January 2012 through September 2014, "BMH knowingly submitted or caused to be submitted a number of outpatient laboratory claims lacking documentation necessary to support reimbursement by Medicare and Medicaid." Doing so was a violation of the federal False Claims Act and the Vermont False Claims Act, stated a press release issued Monday afternoon.
The $1,655,000 will be divided between the federal Medicare, federal Medicaid, and Vermont Medicaid programs to which BMH submitted the alleged false claims.
"Pursuant to the settlement agreement, the settlement and payment are neither an admission of liability by BMH, nor a concession by the United States or State of Vermont that their claims are not well founded," stated the press release.
According to the press release, Amy Beth Main filed a complaint against BMH under the qui tam provisions of the federal False Claims Act. Qui tam lawsuits are a type of whistleblower lawsuit that rewards whistleblowers in successful cases where the government recovers funds lost to fraud.
According to Norman Watts, of Watts Law Firm, in Woodstock, Main will receive between 15 and 20 percent of the settlement, from which he will recover his attorney fees.
"Amy Beth worked for the hospital in an administrative role in the financial services department," said Watts. "She is an experienced administrator in health care and she observed irregular, inappropriate, improper and illegal billings."
Watts contended Main, who lives in Perkinsville, "protested internally ... vigorously" but her protestations were ignored. Watts also told the Reformer that after BMH "made life miserable for her," she quit her job.
"She came to me because we have handled similar actions in the state and federal arena," he said.
Watts told the Reformer he and his client are satisfied with the conclusion of the investigation.
"It was hugely stressful for her to live and work under those conditions," said Watts.
In a press release that was issued shortly after the notification from the U.S. Attorney's Office, BMH stated it had "voluntarily self-disclosed to the Office of the Inspector General for the U.S. Department of Health and Human Services that BMH received overpayments as a result of this billing issue."
According to the press release, "These issues were not present in claims submitted after September 2014 as a result of internal corrective actions taken."
The allegations, stated the BMH press release, were in regard "to coding of claims submitted for certain laboratory tests performed between January 2012 and September 2014. Specifically, that, in some instances, the clinicians' orders for laboratory tests did not appear to adequately document the diagnosis code included on the billing claim form as required."
Beginning in early 2016, BMH "promptly undertook a detailed internal investigation of the issue ..." stated the press release. "BMH fully cooperated with the subsequent OIG investigation. There have been no allegations that the services billed for were not provided or unnecessary; only that they were not properly documented. In reaching this settlement agreement, BMH does not admit to any intentional wrongdoing."
"BMH has made substantial investments within our Patient Financial Services department to address the matter," stated Jonathan Farina, BMH Chief Compliance Officer. "We take issues like this very seriously, and invest considerable time and resources into creating a robust, compliant billing process. Since learning of this billing issue, BMH improved both systems and personnel operations to correct the problem and ensure that we are doing our utmost to comply with the complex requirements for proper billing to all payers."
"Health care providers doing business in Vermont need to have systems in place to ensure that the claims they submit for taxpayer reimbursement are valid under the governing rules and regulations," stated United States Attorney Christina E. Nolan. "We will hold accountable those who knowingly or recklessly bill the government for health care services without proper documentation to support their claims."
The case was investigated by the United States Attorney's Office for the District of Vermont, with assistance from the Office of the Inspector General of the Department of Health and Human Services, and by the Medicaid Fraud and Residential Abuse Unit of the Vermont Attorney General's Office. Assistant United States Attorney Owen C.J. Foster handled the matter on behalf of the United States. Vermont Assistant Attorney General Steven J. Monde of the Medicaid Fraud and Residential Abuse Unit represented the state of Vermont. Kevin Henry and Anne Cramer of the law firm Primmer Piper Eggelston & Cramer, PC represented BMH.
Bob Audette can be contacted at firstname.lastname@example.org.