Legal, Hospitals

Feds slap UPMC, cardiothoracic surgery chair with billing fraud suit

The lawsuit alleges that UPMC and the chair of its cardiothoracic surgery department knowing submitted false claims for concurrent surgeries that violated regulations. But, according to UPMC, there is no regulation that prohibits overlapping surgeries or billing for them.

The United States has sued Pittsburgh-based UPMC, its physician group and the chair of its cardiothoracic surgery department for violating the False Claims Act by billing — for what the government characterizes — as concurrent surgeries.

The lawsuit claims that UPMC and the other defendants knowingly submitted hundreds of fraudulent claims to Medicare, Medicaid and other government programs over the past six years.

Specifically, the lawsuit alleges that Dr. James Luketich, UPMC’s longtime cardiothoracic surgery department chair, performs as many as three complex surgical procedures at the same time and does not participate in all of the “key and critical” portions of the surgeries.

As a result, patients experience hours of anesthesia time, which is medically unnecessary, as he moves between operating rooms, the suit claims. This is in violation of regulations that prohibit teaching physicians, like Luketich, from performing and billing the government for concurrent surgeries that increase surgical volume and thereby increase revenue.

According to UPMC, there is no law or regulation that prohibits overlapping surgeries or billing for them.

“The government’s claims are…based on a misapplication or misinterpretation of UPMC’s internal policies and CMS guidance, neither of which can support a claim for fraudulent billing,” said Paul Wood, chief communications officer at UPMC, in an email. “UPMC and Dr. Luketich plan to vigorously defend against the government’s claims.”

The lawsuit itself concedes that many of Luketich’s patients are elderly, frail and very ill, he added.

“When treating these patients, Dr. Luketich leads teams of highly skilled surgeons and other clinicians through complex procedures that frequently last more than 12 hours,” Wood said.

In addition to the allegedly fraudulent billing, the government contends that UPMC willfully ignored complaints by employees and staff regarding the surgeon’s “hyper-busy schedule, his refusal to delegate surgeries and surgical tasks to other attending physicians… [and] protected him from meaningful sanction…” thereby putting his patients at risk.

“Luketich’s surgical practices also defy the standard of care, abuse patients’ trust, inflate anesthesia time, increase the risk of complications to patients, and — on at least several occasions during the Claims Period – have resulted in serious harm to patients,” the lawsuit alleges.

The United States lawsuit, which was filed Thursday in the U.S. District Court for the Western District of Pennsylvania, is based on a two-year investigation into allegations brought by former UPMC physician Dr. Jonathan D’Cunha under the False Claims Act’s whistleblower provisions.

False Claims Act enforcement has been robust during the first half of the year, with the Justice Department announcing resolutions totaling more than $393 million, according to a report from law firm Gibson Dunn.

The firm predicts that “more aggressive and forward-leaning [False Claims Act] enforcement may well be on the horizon.”

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