Ex-UPMC employees return to court
Network says suit on incentive program had ‘no merit’
Health care giant UPMC lost money on bonuses it paid to neurosurgeons for years as part of a strategy to make money on the back end when doctors referred patients to UPMC hospitals, according to a lawsuit filed last week in U.S. District Court, Western District of Pennsylvania.
The lawsuit, filed by three former UPMC employees, including two doctors, was an amended version of one filed in July 2016. U.S. District Court Judge Cathy Bissoon dismissed the original complaint in June, with a terse warning that the amended complaint would be the plaintiffs’s “one last, best chance.”
UPMC has until Aug. 15 to respond to the amended complaint, but in a prepared statement, the Pittsburghbased hospital network said the lawsuit had “no merit” and the system would again move for its dismissal.
If successful, plaintiffs in the three-count civil lawsuit could receive treble damages based on the sum that Medicare was unlawfully billed. Pursuing the lawsuit are J. William Bookwalter, Robert Sclabassi, both physicians, and Anna Mitina, an operating room technician.
The plaintiffs are represented by the Downtownbased Del Sole Cavanaugh Stroyd LLC and Stone Law Firm LLC. Neither the plaintiffs nor their lawyers were available for comment.
The new lawsuit contains more detailed information than the original version. It states that although the strategy initially cost UPMC money, it ultimately resulted in higher revenue from ancillary services from patient referrals from 2006 until 2015.
The doctor incentive program, according to the lawsuit, violated federal law and resulted in a variety of illegal practices that pumped up physician billings, including performing more complex medical procedures than were necessary and having lesser trained medical professionals fill in for doctors in doing operations.
Physician “residents, and in certain situations physician assistants, perform complicated neurosurgical procedures without the supervision, involvement or physical presence of an attending/teaching physician,” the lawsuit stated. “The attending/ teaching physician never entered the operating room during surgeries performed on their patients, instead leaving the surgery to be performed entirely by the fellow, resident and/or physician assistant.”
Fellows and physician residents essentially are student doctors undergoing additional training; physician assistants are two-year master’s degree trained medical professionals with clinical training.
According to the lawsuit, doing more complex surgical procedures than were necessary, having lesser trained medical professionals perform operations in place of neurosurgeons and other practices inflated the work units — which are comparable to billable hours charged by attorneys — that the doctors received for doing various medical procedures. The result was higher reimbursement paid to UPMC by Medicare, the lawsuit states.
For example, neurosurgeon Matt El-Kadi recorded 56,729 work units in 2009, according to internal UPMC documents cited in the lawsuit, when just 15,077 units represented the 90th percentile among neurosurgeons nationwide that year, according to a survey by a trade group, The Medical Group Management Association, which was cited in the court documents.
Medicare requires teaching physicians to stand “elbow to elbow” with training medical professionals, but the lawsuit alleges that attending doctors were sometimes not in the room. Without admitting any liability, UPMC paid the U.S. Justice Department $2.5 million last year to settle several claims that were contained in the earlier whistleblower suit.