In America today, many hospitals are owned and controlled by massive corporations that operate large chains of hospitals throughout the country. As a result, your local hospital may not be locally owned or controlled. Instead, it might be more akin to a McDonald’s restaurant, owned and controlled by some large corporation with a faraway headquarters.
Although this type of “chain” ownership can often lead to efficiency, it can also lead to serious problems. More and more often, the day-to-day decisions of running hospitals are made by business people who work in the corporate suites, not doctors and nurses who actually deliver care to patients.
Many times, these decisions are made to drive profits rather than to serve the best interests of the patients. Many times these decisions can also lead to Medicare and Medicaid fraud.
Unnecessary inpatient admissions: Fraud by Hospitals
One example is the process for determining hospital inpatient admission. In a typical example, a patient arrives at the emergency room with a given medical condition. The ER doctor must make a decision whether the patient can be seen and treated as an “outpatient” then sent home, or whether the patient needs to be admitted to the hospital as an “inpatient,” which normally involves staying overnight in the hospital.
Obviously, the hospital makes more money if the patient is admitted.
Under the rules and regulations that govern the Medicare and Medicaid systems, the doctor must make a medical judgment based on medical necessity as to whether the patient truly needs to be admitted as an inpatient.
However, the corporate overlords can often influence these decisions by imposing quotas, incentives and punishments that drive doctors to increase admissions. As an example, hospitals can employ admissions quotas with computer systems that track admissions per doctor, so that everyone can see which doctors are “in the lead” for admitting patients. These doctors may receive more favorable treatment or compensation.
On the other hand, doctors who fall behind on their quota might receive less favorable treatment. Those who complain might be retaliated against, alienated, or even fired.
Recent years have seen several large False Claims Act or qui tam cases brought by whistleblowers who work for hospital chains. These whistleblowers noticed patterns of medically unnecessary inpatient admissions. In extreme cases, whistleblowers have reported inpatient admissions for something as minor as a 98.7° “fever.”
If you work in a hospital, you may have seen a pattern of unnecessary inpatient admissions. You may have even been pressured to agree, consent, or stop complaining about these types of inpatient admissions. If you know about this type of fraud, you may be eligible to become a whistleblower and may be entitled to receive a portion of any recovery made by the Government.
If you think you have a potential whistleblower claim, you should consult an attorney knowledgeable with whistleblower cases, particularly with healthcare fraud cases, before taking or copying any documents at your workplace. Contact one of our lawyers for a free and confidential consultation.