Institute of Cardiovascular Excellence: Creating Diagnoses to Get Paid

The Institute of Cardiovascular Excellence and its cardiologist in Ocala, Florida agreed to pay $2 million in the ICE 2016 settlement over alleged unnecessary peripheral-artery procedures and Medicare copayment kickbacks. They also agreed to release their claims to $5.3 million in suspended Medicare funds.

In its June 30, 2016 announcement, the Justice Department said the settlement resolved allegations of improper billing to Medicare, Medicaid and TRICARE. The department said the alleged conduct made the physician the highest-paid Medicare cardiologist in the country in 2012 and 2013.

The government’s account connected the cath lab with the billing desk: overstated blockages, diagnoses selected to get claims paid, and promises that patients would not have to pay their share. Two whistleblower cases brought the allegations forward, and the government joined them. One whistleblower had managed the ICE account for its outside billing company, with access to the practice’s offices, staff and Medicare billings.

Peripheral-Artery Procedures Without the Clinical Support

The government alleged that ICE and its cardiologist performed excessive, medically unnecessary and inadequately documented peripheral-artery procedures. Patients’ medical histories, records and symptom severity did not support many of the interventions billed to federal health care programs, according to the settlement announcement.

The government’s complaint went further. It alleged that when tests showed arterial stenosis, or narrowing, the defendants overstated the blockage to justify angioplasty, atherectomy and stent implantation. It also alleged that they often proceeded without exhausting noninvasive treatment or ruling out other causes of the patient’s symptoms.

The complaint described a consultant’s warning that patients scheduled for specific cath-lab procedures often ended up receiving additional, unplanned diagnostic imaging. According to the consultant’s memo quoted in the complaint, supporting documentation was not always available. The alleged problem started before the bill went out.

Medicare usually packages an implanted device into payment for the procedure. The provider bills for doing the procedure, so the reason for doing it matters to payment. For a cath-lab insider who saw the stent placed, ICE’s case puts the question plainly: what clinical findings supported that intervention? The government alleged that the practice overstated those findings to justify procedures.

Diagnoses Selected to Get Claims Paid

The government alleged that ICE used diagnosis lists and record-keeping shortcuts to obtain Medicare reimbursement. Its complaint described an “auth cheat sheet” listing codes that supported payment for the practice’s frequently performed tests and treatments. Staff allegedly relied on those “payable diagnoses” when ordering procedures to reduce Medicare rejections.

A denial could trigger another search for a diagnosis. According to the complaint, after prepayment medical reviews rejected claims, the defendants consulted Medicare’s local coverage policies for codes that would support reimbursement. They then added codes to medical records, sometimes without proper clinical analysis or approval, and resubmitted the claims.

The complaint quoted a cath-lab director’s email to an employee about her successor. It put the pressure to get paid beside an assurance about quality:

We see the absurdity: creating diagnoses to get paid, while maintaining good patient care. In the same sentence. The payment problem had become a diagnosis problem.

The billing whistleblower’s complaint described another way documentation could change the money. According to that complaint, Partners in Practice translated separately dictated accounts of the same cath-lab procedures into billing codes. The whistleblower alleged that the cardiologist’s accounts produced higher reimbursements than a nurse’s accounts. In one example, the alleged difference was $3,182, or 63%.

That comparison gives a billing insider something concrete to recognize: different accounts of the same encounter producing different claims. The whistleblower attributed the higher amounts to additional procedures appearing in the cardiologist’s dictation.

Copayment Waivers That Encouraged More Procedures

The Justice Department alleged that ICE and its cardiologist routinely waived the 20% Medicare copayment regardless of financial need, inducing patients to accept unnecessary and invasive procedures. Under that alleged arrangement, the patient received the financial benefit. Medicare received the claim.

The government’s complaint described how that promise survived the arrival of an actual bill:

According to the government, those waivers removed patients’ financial incentive to question the excessive procedures. Sending a statement and telling the patient to disregard it served very different purposes. The billing system could show a balance while the patient heard a promise of free care.

The 2020 Journal of Forensic and Investigative Accounting paper A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud explains why a waived bill can belong in a kickback analysis: a routine waiver gives the patient something of value that can influence the choice of provider. Its analysis also places the request for government payment at the center of a False Claims Act case. At ICE, the government’s alleged connection was direct: remove the patient’s payment obligation, encourage the procedure, and bill the federal program.

What the ICE Settlement Covered

The cardiologist also agreed to exclusion from federal health care programs for three years, followed by a separate three-year integrity agreement with the Department of Health and Human Services Office of Inspector General.

The Justice Department’s Civil Division, the U.S. Attorney’s Office for the Middle District of Florida, HHS-OIG and the Defense Health Agency handled the case.

How Much Is a Whistleblower Claim Worth?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In this settlement, the Justice Department announced a collective award of $1.3 million for the two whistleblowers together.

What Evidence Is Needed to Prove Fraud?

ICE’s complaints connected the clinical justification, the procedure performed and the claim for payment. They drew on test findings, dictated notes, diagnosis lists, denied claims, resubmissions and patient billing communications.

The outside billing account manager’s view mattered because it crossed those boundaries. Her complaint described firsthand observations in the offices, conversations with staff and review of billing documents. A cath-lab employee may recognize the procedure account. A coder may recognize the diagnosis added after a denial. A patient-account employee may recognize the instruction to disregard a bill. We examine how those accounts fit together and what they show about the decisions behind the claim.

The clinical justification also runs through other cardiovascular cases. In the EMH Regional Medical Center and North Ohio Heart Center settlement, the government alleged unnecessary angioplasty and stent placement in patients whose vessels were not sufficiently blocked to require the procedures. The shared issue is the link between what the artery showed and what the provider billed.

A later civil settlement involving Qin Medical carried admissions about routine scheduling of vascular procedures every three months, inadequate documented symptoms and knowledge that Medicare required documented clinical justification. Across these accounts, the useful comparison is between the reason recorded for an intervention and the system that kept producing interventions and claims.

You Saw the Procedure and the Paperwork

If you worked in the cath lab or billing office and saw diagnoses added to secure payment or patient balances waived to keep procedures coming, talk with our whistleblower experts about what happened inside the practice. We build the case from that knowledge and bring in healthcare fraud whistleblower lawyers who understand medical-necessity and billing disputes. We stay beside you through the whole process, turning your view from inside into your strongest healthcare fraud whistleblower case.