Tennessee Cardiologist Stent Settlement: Unnecessary Stents and Bills for Substitute Doctors

A Tennessee cardiologist agreed to pay $1.15 million in the 2013 stent settlement over allegations of medically unnecessary cardiac stents and improper Medicare billing for substitute doctors. Patients allegedly underwent heart procedures they did not need, and the cardiologist billed Medicare and Medicaid for them.

What the Stent Settlement Covered

The Justice Department announced the civil False Claims Act settlement on December 19, 2013. The settling cardiologist owned Delta Clinic, with offices in Jackson and Lexington, Tennessee, and had privileges at Jackson-Madison County General Hospital and Regional Hospital of Jackson.

The government alleged that he placed medically unnecessary cardiac stents in Medicare and Medicaid patients from January 1, 2005, through December 31, 2008. It separately alleged that he improperly billed Medicare for services performed by substitute physicians when he was available to perform them himself.

The cardiologist also entered an Integrity Agreement with the Department of Health and Human Services Office of Inspector General. It required enhanced accountability and monitoring by both internal and independent external reviewers.

Unnecessary Stents and Symptoms Patients Did Not Have

The whistleblower’s complaint alleged that false descriptions of patients’ symptoms helped justify unnecessary heart procedures. It described a sequence beginning with unnecessary diagnostic studies, including stress imaging and echocardiography, followed by ambulance transport of nursing-home patients to the hospitals for catheterization, coronary angiography and interventions.

The complaint’s sharpest allegation concerns what went into the patient records:

The alleged falsehood was specific: the records described chest pain that patients did not have. Someone who heard the patient’s symptoms and then saw the dictated record could recognize that difference. That is more concrete than a general concern that a practice performs too many procedures.

The government’s settlement announcement focused on allegations that the cardiologist placed those devices in patients who did not need them and billed the public programs for the placements. The complaint describes the broader alleged course of testing and treatment that led patients into the hospitals.

Medicare’s medical necessity requirement limits payment to care that is reasonable and necessary for diagnosis or treatment. In this case, the alleged false symptom account goes directly to that reason: why the patient was being sent for a heart procedure.

Substitute-Physician Billing and Who Did the Work

The substitute-physician allegation concerned Medicare billing for another doctor’s services while the cardiologist was available to do the work himself.

For someone who worked on scheduling or claims, the relevant knowledge may concern when another doctor provided care, whether the regular cardiologist was available and how the service was billed. That is the part of this case a headline about stents misses. A scheduler may know the doctor’s availability, while a billing employee may know how the substitute’s work appeared on the claim.

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 false reimbursement requests that misstate the services provided. For a substitute-doctor allegation, that makes the description on the bill worth examining alongside who actually did the work. Our review brings the staffing account and billing account together, with the insider who understands how the practice operated.

Unnecessary-Stent Claims Can Reach the Hospital’s Bill

The Tennessee complaint alleged that unnecessary cardiac procedures produced unnecessary hospital admissions. For a hospital insider, the episode may be familiar from the admission and procedure records, even when the physician’s office handles a separate bill.

In Maryland, St. Joseph Medical Center’s $22 million civil settlement covered allegations of referral payments and hospital reimbursement for unnecessary stents.

What Evidence Is Needed to Prove Fraud?

For these allegations, useful evidence connects the patient’s symptoms and treatment, or the treating doctor’s identity and availability, to a government claim. Our work with an insider starts with what they know directly about those events.

For the alleged false symptoms, we would examine the difference between what the patient reported and what the treatment record said. For substitute billing, we would examine who performed the service, whether the cardiologist was available and how the practice billed Medicare. An insider may understand the clinical work, the staffing or the billing without seeing all of them.

The accounting paper also examines what the person submitting information knew about its truth. Applied here, our review asks who knew about a discrepancy and how that information reached the people responsible for the bill. We bring the clinical and billing expertise together so the case reflects how the practice worked.

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. A physician whistleblower brought the qui tam case behind this settlement, and the government’s announcement said the physician would receive a share.

How We Help Cardiology Insiders

If you know why stents were ordered or how substitute doctors’ services were billed, we can build the case with you and stay beside you through the process. We bring in healthcare fraud whistleblower lawyers who understand medical necessity and physician billing. Speak with our whistleblower experts about your strongest cardiology whistleblower case.