Dive Brief:
- The Department of Justice has filed a complaint against Prime Healthcare, alleging the California-based hospital system led a deliberate strategy to increase its admissions of insured patients “without regard to medical need," Fierce Healthcare reports.
- The move came just a month after the DOJ joined a related whistle-blower case against Prime.
- Medicare beneficiaries were specifically targeted at some Prime hospitals, with the option of observation status being officially eliminated from ED admission forms, the complaint stated.
Dive Insight:
The complaint outlined systematic pressures on Prime hospital employees that included arbitrary inpatient admission quotas of 20-30%, as well as confrontations with physicians over "missed admissions" opportunities for patients with minor ailments including ear infections and urinary tract infections.
In addition, the complaint stated that Prime modified the independently developed Milliman Guidelines, which it selected to use for its admission criteria, before making them available to hospital staff in California. The changes included the omission of alternatives to admission and the addition of criteria to justify admissions.
Prime "rarely, if ever" identified the alterations it made, leading staff to believe they were following admission standards accepted by other hospitals and insurers across the U.S., according to the DOJ.
As a result of Prime's practices, the "Defendants have claimed and received millions of dollars in inflated reimbursements for medically unnecessary inpatient admissions," the DOJ argued. "In so doing, Defendants have burdened the finite resources of the Medicare program and put their own pecuniary interests ahead of the interests of Medicare."