Becker's Hospital Review

12 CFO / FINANCE DOJ Sues UnitedHealth Over $1B+ in Medicare Claims By Morgan Haefner T he Justice Department sued Minnetonka, Minn.-based United- Health Group May 16, alleging the payer defrauded Medicare at least $1 billion in false claims. In the 79-page lawsuit filed in a Los Angeles federal court, the Justice Department alleged the payer knowingly inflated risk adjustment payments by providing the government inaccurate data about the health status of its beneficiaries. Department officials cited United- Health's "one-sided" chart review process that reportedly didn't ad- dress errors elevating its revenues. The department also alleges the payer ignored "invalid diagno- ses from healthcare providers with financial incentives to furnish such diagnoses." The DOJ filing is an intervention in a lawsuit filed under seal in 2011 by Benjamin Poehling, former finance director of United- Healthcare Medicare and Retirement. That suit alleges United- Health billed Medicare higher payments for patients by making patients appear sicker than they were. In an earlier statement to StarTribune, UnitedHealth spokesperson Matt Burns said the pay- er denied the claims and has "been transparent with [CMS] about our approach under its unclear policies. We reject these claims and will contest them vigorously." is is the second lawsuit the department has filed against the in- surer this month. e move follows the department's decision to intervene in a whistle-blower suit filed by James Swoben in 2009. It concerns separate but similar allegations. n OIG Tags Arkansas Hospital for Incorrect Billing By Ayla Ellison T he University of Arkansas Medical Sciences Medical Center in Little Rock failed to comply with Medicare billing require- ments for 16 of 130 inpatient claims reviewed by HHS' Office of Inspector General for the audit period of Jan. 1, 2013, through Dec. 31, 2104, according to an OIG report. The 16 claims that did not comply with Medicare billing require- ments resulted in the hospital receiving $197,172 in overpayments, according to the OIG. Extrapolating from the sample results, the OIG estimated University of Arkansas Sciences Medical Center received at least $278,000 in overpayments from Medicare during the audit period. Based on its findings, the OIG recommended the hospital refund $278,000 to the Medicare contractor, to which CMS outsources the processing and payment of claims submitted by hospitals. The OIG also recommended the hospital exercise reasonable diligence to identify and return any additional overpayments outside of the au- dit period and strengthen controls to ensure full compliance with Medicare requirements. In written comments, University of Arkansas Sciences Medical Center agreed nine of the 16 claims identified by the OIG contained billing errors. The hospital reserved the right to appeal the OIG's determina- tions and the overpayment estimates for the remaining seven claims. After reviewing the hospital's comments, the OIG maintained its findings and recommendations. n Georgia Hospital to Close After Years of Financial Troubles By Ayla Ellison S avannah, Ga.-based Optim Healthcare an- nounced April 25 that it will close Optim Medical Center-Jenkins in Millen, Ga., on June 24. Optim said the hospital has faced financial chal- lenges for several years caused by dwindling pa- tient volumes and declining reimbursement from government payers. Optim said the hospital also has major infrastructure challenges, which would require significant investments to address. To help stem future losses, the system will con- solidate the services of Optim Medical Cen- ter-Jenkins with its facility about 20 minutes away in Sylvania, Ga. "We made this difficult decision to close our Jen- kins facility following a lengthy analysis during which we looked for ways to keep Jenkins open," said Optim. When the hospital closes, 55 full- and part-time jobs will be eliminated, according to WBJF. n

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