- Adventist Health System, a nonprofit that operates healthcare organizations in 10 states, has agreed to pay the U.S. $115 million to settle allegations it violated the False Claims Act.
The allegations arose from two whistleblower cases.
The settlement resolves Adventist violated the measure by maintaining improper compensation arrangements with referring physicians and miscoding claims.
The settlement resolves allegations Adventist submitted false claims to the Medicare and Medicaid programs for patient services referred by employed physicians who received bonuses based on a formula that improperly took into account the value of the physicians’ referrals to Adventist hospitals.
In addition, the settlement resolves allegations Adventist submitted bills to Medicare for its employed physicians’ professional services containing certain improper coding modifiers, thus receiving greater reimbursement for these services than entitled.
According to a prepared statement from the Department of Justice’s Office of Public Affairs, the settlement serves to highlight the government’s emphasis on combating healthcare fraud. Formed in 2009 as a partnership between the Attorney General and HHS, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative attempts to reduce and prevent Medicare and Medicaid financial fraud.
According to DOJ, one of the more powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a more than $25 billion through False Claims Act cases, with more than $16 billion of that amount recovered in cases involving fraud against federal healthcare programs.