On May 16, the U.S. Department of Justice announced that Cape Cod Hospital agreed to pay $24.3 million to resolve allegations that it violated the False Claims Act by submitting claims to Medicare for transcatheter aortic valve replacement (TAVR) procedures which failed to comply with procedures to evaluate patient suitability.
The settlement resolves whistleblower claims brought forward by Richard Zelman, a physician formerly employed by Cape Cod Hospital, in a qui tam lawsuit. As part of the settlement, Zelman will receive approximately $4.36 million.
Under the qui tam, or whistleblower, provisions of the False Claims Act, a private party can file an action on behalf of the U.S. and be eligible to receive 15-30% of any recovery.
The settlement addresses allegations for hundreds of knowingly submitted claims by Cape Cod Hospital between November 2015 to December 2022. According to the government, Cape Cod Hospital began offering TAVR procedures for patients suffering from aortic stenosis, a serious heart condition that restricts heart blood flow to the rest of the body, which involves replacing the damaged heart valve with an artificial one. According to the Medicare’s rules, hospitals have to conduct independent examinations to evaluable patients’ suitability for TAVR and make the document the rationale of clinical judgment available to the medical team prior performing the TAVE procedure.
According to the government, “Cape Cod Hospital knowingly submitted hundreds of claims to Medicare for TAVR procedures that did not comply with the applicable Medicare requirements. In some instances, not enough physicians examined a patient’s suitability for the procedure, while in other instances the physicians failed to document and share their clinical judgment with the medical team responsible for the TAVR procedure.“
“Hospitals that participate in the Medicare program must abide by applicable coverage and reimbursement rules,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division.
“We are committed to pursuing allegations of False Claims Act violations as we work to protect the integrity of the taxpayer-funded Medicare program, and we encourage the public to come forward with information about such conduct.” Roberto Coviello, Special Agent in Charge with the U.S. Department of Health and Human Services, Office of Inspector General, said.
On July 25, a bipartisan group of senators introduced the False Claims Amendments Act of 2023, which address a few technical loopholes undermining the success of the FCA. The bill is widely supported by whistleblower advocates.
National Whistleblower Center (NWC) has issued an Action Alert calling on Congress to pass the bill.
Join NWC in Taking Action:
Demand that Congress strengthen the False Claims Act
Further Reading:
Bipartisan Legislation Unveiled to Strengthen False Claims Act