Hospitals Settle Fraud Claims

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By Amy Fox
By Loreto Cruz III

MARION -- The parent company of Heartland Regional Medical Center and dozens of other hospitals across the country will pay nearly $100 million to settle claims of defrauding Medicare and Medicaid. 

A former employee at the Marion hospital filed the claims against Community Health Systems. That lead to an investigation by the U.S. Department of Justice. 

The government alleges 119 CHS hospitals nationwide, including four in Southern Illinois, submitted fraudulent claims involving Medicare, Medicaid, and TRICARE patients from 2005 to 2010.

"The personnel that were doing the admitting had to justify to the management why a medicare patient, and keep in mind this was just the Medicare patients this wasn't the private pay patients, why a Medicare patient wasn't admitted instead of why was it necessary to admit them," said Marion lawyer Ronald Osman.

Osman represents the person who brought the claims against the company, a former EMS Director for Heartland Regional. 

The employee alleges CHS hospitals admitted ER patients to the hospital even though it wasn't medically necessary, had a corporate policy requiring it, and placed quotas on hospitals for those Medicare and Medicaid admissions., all to increase reimbursements
    
"It's financial," said Osman.  "The facilities are there at fixed costs, so if they have an empty bed, if they can put somebody in it, why it makes financial sense to do so."

The terms of the settlement call for the company to pay more than $97 million in penalties and damages.

In a statement , Community Health Systems denies any wrongdoing saying,  "The question of when a patient should be admitted is, and always has been, a matter of medical judgment by the individual physician responsible for a patient's care."

The company's CEO goes on to say, "As we move forward now, I am certain this experience will make us a stronger and even more committed organization."

As part of the agreement, the government will also be allowed to monitor the organization closely in the coming months to make sure they are complying with policies and procedures.

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