Mark Green, U.S. attorney for the Eastern District of Oklahoma, said in a news release, “Health-care fraud is a tremendous problem in eastern Oklahoma as well as across the nation. Fraud, such as billing for services that aren’t necessary, costs the taxpayers of Oklahoma thousands of dollars. The False Claims Act is a valuable weapon in the government’s arsenal to combat these types of abuses.”
The hospital, in an email sent Friday evening, denied the allegations in the lawsuit, in which a physician, who has not been on the medical staff since 2010, is accused of performing unnecessary sinus surgeries.
The hospital was accused of submitting inappropriate claims to Medicare and Medicaid.
Commenting on the settlement, the hospital said, “We do not believe that the hospital submitted inappropriate claims and we did not admit to any wrongdoing or liability in this case. We negotiated the settlement to avoid the potential for long and more costly litigation.
“The Medical Center of Southeastern Oklahoma is committed to providing quality care for patients. We have an excellent medical staff, including some outstanding doctors who have come to our community over the past couple of years. Our nursing team and other hospital employees are professional, compassionate caregivers who provide great care for their patients. Our hospital has been working to continuously improve quality and to increase the level of services available for local residents. For example, we were recently awarded Level III trauma status in our Emergency Department and also recently received stroke certification. Our goal is to provide quality care, close to home, for local residents, and we will continue to do everything we can to earn their trust and confidence.
“We have recently reinforced our compliance program with a new alert line and staff education. We are committed to acting with integrity for the good of our patients and to complying with government regulations.”
The U.S. Attorney’s Office said the settlement resolves allegations that MCSO submitted claims to SoonerCare for surgical procedures performed by Castro and related hospital services that were not medically necessary. The surgical procedures in question were functional endoscopic sinus surgeries performed by Castro on children who were SoonerCare beneficiaries.
According to the U.S. Attorney’s Office, Castro performed FESS’s on children that were not medically indicated, and Castro and the hospital billed SoonerCare for the unnecessary surgeries and related hospital services. The settlement also resolves claims that MCSO billed SoonerCare for hospital services related to FESS’s that Castro did not actually perform.
The allegations that the government has settled with MCSO and HMA were raised in a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act. The act allows private citizens with knowledge of fraud to bring civil actions on behalf of the government and to share in any recovery. The whistleblower, Sandra Simmons, will receive $159,750 as part of the settlement.
According to the U.S. Attorney’s Office, this civil settlement and the government’s intervention illustrate the government’s emphasis on combating health-care fraud and mark another achievement for the Health Care Fraud Prevention and Enforcement Action Team initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.
One of the most powerful tools in this effort is the False Claims Act, according to federal officials. Since January 2009, the Justice Department has recovered more than $19 billion through False Claims Act cases, with more than $13.6 billion of that in cases involving fraud against federal health-care programs.