St. Helena Hospital: Two Decisions Behind the Medicare Bill

St. Helena Hospital agreed to pay $2,250,000 in its 2014 PCI settlement over allegations of medically unnecessary angioplasty and unnecessary inpatient admissions billed to Medicare. A former hospital employee brought the False Claims Act case. The government alleged that patients underwent heart procedures they did not need and that the hospital charged Medicare for that care.

St. Helena was an acute care hospital within the Adventist Health System. The Justice Department announced the settlement on December 19, 2014. The allegations reached both the decision to perform angioplasty and the decision to admit the patient instead of providing less costly outpatient care.

What St. Helena Allegedly Billed to Medicare

The government alleged that St. Helena knowingly charged Medicare for medically unnecessary percutaneous coronary interventions from January 1, 2008, through July 31, 2011.

The government also alleged that St. Helena unnecessarily admitted angioplasty patients who should have received outpatient treatment. That put the expense of an inpatient stay onto Medicare as well. The alleged harm reached the patient receiving unnecessary care and the public program charged for it.

For a hospital insider, those are different parts of the same patient encounter. A concern about why an intervention was ordered points toward the clinical decision. A concern about why the patient was admitted points toward the setting of care. Someone working in admissions may know how the stay was classified, while someone involved in the procedure may understand the reason given for performing it.

Why Inpatient Admissions Mattered to Medicare

The inpatient-admission allegation was about charging Medicare for a more expensive setting than the patients needed. Hospital device reimbursement helps explain the financial importance of that choice.

Medicare generally includes implantable and insertable devices in its outpatient payment for the procedure. The money follows the hospital service that includes the device.

A hospital claim can still carry device codes and charges when the device’s cost is included in the procedure payment. The device and the hospital service are therefore connected in the payment system. For someone selling a device to a hospital, the hospital’s reimbursement can become part of the sales conversation.

The 2020 Journal of Forensic and Investigative Accounting paper A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud describes a recurring billing problem: requests for payment for more expensive categories of care than were provided. At St. Helena, the government specifically challenged the need for the interventions and for inpatient treatment.

Other Cases Put the Admission Decision Under Scrutiny

Rex Healthcare faced a similar allegation about inpatient billing for minimally invasive procedures. The Justice Department alleged that the Raleigh, North Carolina hospital routinely classified those procedures as inpatient admissions to increase Medicare reimbursement, without medical necessity for the more expensive admissions.

That case covered kyphoplasty and other procedures. The connection to St. Helena is the alleged use of inpatient status to obtain payment for a more expensive setting of care.

In a separate case, a whistleblower complaint alleged that FoxHollow Technologies sales staff encouraged hospitals to convert outpatient claims to inpatient claims.

What Evidence Is Needed to Prove Fraud?

For the allegations resolved at St. Helena, the useful connection runs from the reason for angioplasty to the reason for inpatient admission and the resulting Medicare claim. Our whistleblower experts examine how those decisions fit together, with the insider who understands what happened.

The accounting paper explains why that inside view matters:

A clinical employee may understand the reason given for an intervention. An admissions or billing employee may understand how the encounter became an inpatient claim. A device representative or reimbursement specialist may have seen the sales instructions behind that decision.

Your view may begin with patient care, health care billing, or the reimbursement pitch used to sell a device. We work with you to connect that knowledge to the hospital claims and develop the case around the conduct you actually saw.

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 the St. Helena case, the Justice Department announced that the former employee would receive a portion of the government’s recovery.

Your View of the Hospital’s Decisions

If you saw unnecessary angioplasty, inpatient admissions driven by billing, or device sales advice pushing those admissions, your inside knowledge can be the starting point for a case. We work beside you to build your strongest hospital billing whistleblower case and bring in healthcare fraud whistleblower lawyers who understand medical necessity and device reimbursement. Speak with our whistleblower experts about the decisions behind the Medicare claims you saw.