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The U.S. Attorney’s Office has joined a lawsuit against Sutter Health and the Palo Alto Medical Foundation accusing the health care providers of knowingly submitting wrong or inaccurate diagnosis codes for some Medicare payments, the U.S. Justice Department announced on Tuesday.
The lawsuit alleges that Sutter and the Palo Alto Medical Foundation violated the federal False Claims Act by submitting inaccurate codes that inflated the “risk scores” of patients on the Medicare Advantage program, and enabled Sutter to reap greater reimbursements from the Centers for Medicare and Medicaid Services, which oversees the Medicare program. The lawsuit also alleges that when the Palo Alto Medical Foundation became aware of these inaccurate diagnosis codes, it failed to identify and delete additional potentially inaccurate codes that would result in a higher payment to Sutter.
PAMF’s locations include the Mountain View Internal Medicine Center at 701 E. El Camino Real in Mountain View.
Medicare beneficiaries have the option of enrolling in managed health care insurance plans called Medicare Advantage, also known as Medicare Part C. The plans are owned and operated by private Medicare Advantage organizations or MAOs. Medicare Advantage plans are paid a “per-person” amount to provide Medicare-covered benefits to the beneficiaries.
The Centers for Medicare adjusts the amount of the payment based on demographic information and the health status of each patient in the plan. A patient with more severe diagnoses has a higher adjusted amount, or “risk score.” The government makes a larger payment to the Medicare Advantage plan for that patient, according to the Justice Department. Sutter allegedly submitted the inaccurate diagnoses codes for their patients to the insurers, who then submitted the codes to Centers for Medicare.
As a contracted provider to the insurer, Sutter receives a share of the payments to the insurers from Centers for Medicare.
The lawsuit was filed under the qui tam, or whistleblower, provisions of the False Claims Act, by Kathleen Ormsby, a former employee of the Palo Alto Medical Foundation. The False Claims Act permits private parties to sue on behalf of the government for false claims and to receive a share of any recovery. The act also allows the government to intervene or join in whistleblower lawsuits.
U.S. Attorney Alex G. Tse said in a statement that the government’s participation in the lawsuit illustrates a commitment to protect the integrity of the Medicare Advantage program.
“The share of Medicare beneficiaries enrolled in Medicare Advantage has steadily grown over the past decade, with 19 million beneficiaries enrolled in 2017. It is critically important that the data submitted to the Medicare Advantage program is truthful, because the government relies on this information to set payment levels. We will continue to guard government health programs from companies that improperly maximize their bottom line at taxpayer expense,” he said.
Jody Hunt, assistant attorney general of the Department of Justice’s Civil Division, said that federal health care programs rely on the accuracy of information submitted by health care providers to ensure that patients are afforded the appropriate level of care and that managed care plans receive appropriate compensation.
“Today’s action sends a clear message that we will seek to hold healthcare providers responsible if they fail to ensure that the information they submit is truthful.”
In an emailed statement from Sutter Health, company officials said, “Sutter Health and PAMF are aware of the matter and take the issues raised in the complaint seriously. The lawsuit involves an area of law that is currently unsettled and the subject of ongoing litigation in multiple jurisdictions. We intend to vigorously defend ourselves against the allegations in the complaint.”
Interesting. But here is the scoop from last night’s Mountain View Council meeting – the last action meeting for the 3 members elected 4 years ago (Showalter, Rosenberg and Siegel): The big event for Bay Area TV was a protest against demolishing an apt complex on Rock Street to make way for expensive condos. After midnight, only 3 of 7 Councilmember supported the demolition at this time and the Council voted to deny the project “without prejudice” to a renewed application – mainly to see if more can be done for displaced tenants. Then, at about 12:30am, the Council took up the request for $100 million from the slippery politicians running the Los Altos School District. Councilmember John McAlister, who previously denied having an unlawful conflict of interest, walked away because he had been caught and is being investigated for voting despite his financial conflict of interest The City Council ended up directing staff to prepare (and share with the new City Council) an agreement with the Los Altos School District that guarantees Mountain View a school neighborhood kids can attend. A man and his attorney got up to report that the deal had unlawfully left out entities that own use restrictions on the shopping center property. A lawsuit is already pending. Stay tuned. As one of the 3 stooges used to say: THIS IS ONE FINE MESS YOU’VE GOTTEN (US) INTO.
i used to be a patient of PAMF some years ago. Their charges for normal visits are double or triple than some other provider. I guess somebody has to pay for the beautiful big buildings and parking spaces, lighting etc.. Their additional charges on any specific diagnosis were also high. My experience is nothing to do with medicare. BUt Iam not shocked by their behavior. The doctors won’t even give you useful advice like using triple antobiotic cream for infection etc..so that you can avoid going to hospitals and pay 100s of dollars for infections. I switched over to smaller clinic and the doctors much more helpful and listening to my issues for lesser fees
You mean, of course, Oliver Hardy, not the Stooges. He was always accusing Stan Laurel of getting them into Another Fine Mess, in their comedy-duo films.
Yes, Wikipedia has the quote under catch phrases: https://en.wikipedia.org/wiki/Laurel_and_Hardy#Catchphrases
@ Money Is Corrupting: What exactly does your incoherent rant have to do with the subject at hand — Sutter/PAMF and alleged billing abuses of its Medicare Advantage program??? As for your rant, I suggest you make your highly ignorant housing and school “comments” at proper forums for such comments. Specifically, MV Voice articles on housing and school district issues. You socialist populist housing advocates are pestiferous gadflies.
I stand corrected on the source of the quote. As to relevance of my comment to the article, “money is corrupting” is the common thread.
I had respect for this medical group when they were still Camino Medical Group – before they were taken over by Sutter Health. Now they only care for how much $$ the can wring out of a patient visit. You have to sign an agreement before seeing your doctor the day of your appointment, stating the exact reason your visit is for that day – for example an aching back. If you go in with an aching back and happen to mention your knee also aches, they charge you for TWO visits. They are ridiculous and greedy.
I had an eye exam and then was told to also take the 5 minute test where you look at a screen and click a button when you see a small light appear (takes about 5 or 6 minutes). That was always included as part of the total vision exam, but now they bill you DOUBLE as they consider that “two exams”.
I have never seen a good medical group degenerate as fast as this one, and it’s really pathetic. I’m not surprised at all that they are accused of cheating the government with false claims.
I hope they name the people who are responsible for the fraudulent charges so we know whom to avoid. Also name those people who benefitted from the fraud and claw it back. All of us pay for this in the form of exorbitant premiums.
Last week I ask for two refills for two medicines but my brand new primary doctor say to get yearly physical. My last doctor for so years never tell me this and sent me to lab for levels and then give me refills without bull shit waste for insurance and my money. No physical every time cause he said no need for healthy man like me. I got one every three years or a short appointment. Now they tell me I got to get one once a year to get refills. I have to take time off from work and drive far to get to the clinic.
Sutter gives papers to tell physical exam billing for two charges in one appointment but no waivers to tell physical appointment does not 100% promise we will live long time, not get sick and not die. My brand new primary doctor lie with promises to explain why to get physical. This is 100% unethical on his part and Sutter. I make my family promise to file lawsuit if I die after getting yearly physical. Sutter doctors do not tell negative side effects. My health account said OVERDUE but it is 100% unethical to say this. Sutter give false security to patients and feed off their fears of dying. 100% UNETHICAL AND DECEIT. What good is our health if Sutter destroys it with lies of promises of reasons to get physicals and referrals. Sutter got Mission, Vision & Values on their website but they are lies to the people.
We got to get social health care system in America because corporate business greed and medicine must never mix together. Sutter among all big health network groups are all now about profit over patients while the CEOs earn millions of dollars annually. There are patients rights but Sutter doctors ignore them and are told to generate many billable charges to get more shares. The opinion of weight and appearance is irrelevant.
You said,
“We got to get social health care system in America because corporate business greed and medicine must never mix together.”
You mean you would prefer a government run health care, like the VA?
That should show so that you do not want that. Research that on Google and look at everything that has happened there, and then find out why it is taking so long to fix it. Main reason is the bad doctors, nurses, etc, can not be fired. That is what happens when the government run things.
We need a major reform, but no government run system for me.
Whatever system you want to name it. We need healthcare for everyone because no one should lose their life savings over medical care and get to the point of collections and bankruptcy. If one combined the money of Jeff Bezos, Bill Gates, Mark Zuckerberg, Larry Ellison and rest of wealthy people, the money could fix and reform this nation’s medical care system, homelessness, school budgets and more. Only the rich and politicians can afford the top best medical care while others do not. When Gabby Gifford got shot, she received the best care. If a homeless man from Richmond got shot in the head, he would not get that same kind of care. President George Bush, Sr. got best care without he or his family having to worry about his medical bills. When I talk to old people who say they just moved to USA, never worked a day in USA and are granted Medicaid free programs, housing subsidies, food stamps, I am so disgusted. For USA low to middle class citizens, we get nothing free like that. USA needs to care for their citizens to the fullest.
I find the PAMF and their doctor Group (PAFMG) are more interested in money than health care. If you look close, you can see how they are manipulating the medical treatment and how cleverly they have disguised their chain of liability. Be afraid of this Group.