This settlement stems from a lawsuit originally filed against WMC on October 15, 2007, by Gale Bryden, a former WMC employee who brought the case under the whistleblower (qui tam) provisions of the False Claims Act, 31 U.S.C. § 3730(b). Bryden alleged, among other claims, that WMC committed fraud against Medicare by submitting requests for reimbursement that were inconsistent with patient treatment records, by changing the admission status of patients from outpatient to a higher-paying inpatient status without a physician order, and by billing Medicare for unnecessary inpatient admissions.
The United States conducted an extensive investigation and found evidence to support some of the claims. Today’s settlement specifically resolves allegations that WMC submitted higher-paying inpatient reimbursement claims to Medicare for procedures that had been performed in an outpatient setting, submitted inpatient reimbursement claims for hospital stays where there was no record of a physician ordering inpatient-level care, and submitted inpatient reimbursement claims for services provided to patients who did not meet requirements for inpatient admission. The United States also settled allegations that WMC prolonged inpatient hospital admissions without medical necessity in order to qualify patients for Medicare-covered, long-term care at a skilled nursing facility – a practice that caused Medicare to reimburse for services it would not otherwise have been obligated to pay. WMC voluntarily cooperated with investigators in making records and witnesses available, but denies any wrongdoing.
As provided under the whistleblower provisions of the False Claims Act, Bryden will receive a share of the settlement as compensation for filing the case and assisting the United
States in the course of its investigation. The statute provides for this shared recovery as a means of encouraging citizens to report cases of fraud against the government.
“In this era of increasing health care costs and budget constraints, allegations of Medicare fraud and overbilling must be aggressively pursued in order to protect the integrity of the Medicare system,” said U.S. Attorney Kip Crofts. “We appreciate the assistance of citizens like Ms. Bryden who make the effort to bring these allegations to our attention.”
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Report Medicare & Medicaid Fraud by Calling 1-888-482-6825 or by visiting
www.usawhistleblower.com
