Adventist Health Systems Fined for Overbilling

Adventist Health Systems Fined for Overbilling

Adventist Health System Sunbelt Healthcare Corporation based in Orlando has been fined $115 million for filing both false and inflated insurance claims, and for providing kickbacks to physicians. AHHSHC operates 43 hospitals in 10 states, including Illinois.

The case began in December 2012 when three Park Ridge employees who were aware of the overbilling filed a whistleblower complaint under the federal False Claims Act. They alleged that billing practices, physician recruitment, and compliance were seriously deficient and being conducted in clear violation of the law.

The US Department of Justice investigated their complaint and found numerous examples where the corporation defrauded the US government and states including Florida, Tennessee, Georgia, Texas, North Carolina, and Illinois. In these states, the company overbilled Medicare and Medicaid, and engaged in an illegal scheme wherein the corporation provided compensation to physicians who referred patients to hospitals for treatments.

Any Illinois medical malpractice lawyer knows this is illegal. It is very clearly spelled out in the law because it undermines the physicians impartiality and can lead to considerable expenses being borne by both patients and taxpayers. Further, physician overbilling is a growing problem that costs consumers and taxpayers billions of dollars per year.

In the investigation, 52 physicians, and 10 nurse practitioners were named for having participated in the scheme. These individuals knew the referral of patients to hospitals for care and treatment was unnecessary, yet participated willingly. Indeed, some of them made several million dollars per year.

During the investigation, it became clear that executives at Adventist Health System Sunbelt Healthcare Corporation were aware of the scheme being conducted, but did little to stop it other than issuing minor internal missives to the hospitals involved. They warned that the payments being made were a clear and direct violation of the Stark Act, however, they did not properly follow-up and ensure that the practice had ceased.

At the conclusion of the investigation, the US Justice Department fined the company $118.7 million in total. The corporation has agreed to the settlement in return for protection from further civil sanctions in regard to the issue. However, it does not allow them to rely upon a double-jeopardy defense should criminal prosecution or other administrative action commence.

Overbilling and Medicare fraud are two of the fastest growing crimes an Illinois medical malpractice lawyer must contend with. It is costing taxpayers billions of dollars per year and this case demonstrates that the US Department of Justice is actively pursuing complaints.