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Cape Cod hospital to pay $24.3 million after false Medicare claims reported

Cape Cod Hospital has agreed to pay more than $24.3 million to resolve allegations that it failed to follow Medicare cardiac procedure rules, according to the U.S. attorney’s office.

Investigators found that doctors at the hospital failed to perform patient assessments for transcatheter aortic valve replacement, a procedure known as TAVR that involves replacing a person’s damaged heart valve. patient through an artificial valve, in accordance with Medicare reimbursement rules.

From November 2015 to December 2022, Cape Cod Hospital knowingly submitted “hundreds of claims to Medicare for TAVR procedures that did not comply with applicable NCD (National Coverage Determination) requirements,” according to the settlement , meaning the hospital submitted millions of dollars of false claims to Medicare in violation of the False Claims Act.

What did Cape Cod Hospital do wrong, according to the U.S. Attorney?

In some cases, not enough doctors evaluated a patient’s suitability for the procedure, while other times, doctors failed to document and share their findings with the medical team responsible for the TAVR procedure. .

“Medicare has only authorized coverage for this newly developed cardiac procedure under certain conditions, to ensure patient safety. Cape Cod Hospital ignored these rules and received millions of dollars from Medicare to which it was not entitled. This conduct persisted for years despite internal warnings,” Acting U.S. Attorney Joshua S. Levy of the District of Massachusetts said in a statement. “This investigation and settlement ensures that patient safety comes before the hospital’s bottom line.” »

In a statement, Cape Cod Hospital noted that the settlement did not allege that patients who underwent TAVR procedures were harmed or that Cape Cod Hospital billed Medicare for procedures that did not been carried out.

According to the hospital, many of the physicians who provided the services at issue are no longer employed or contracted to provide services at the hospital. Cape Cod Hospital has since “increased its documentation practices and believes that its cardiac team clinicians, which now include talented cardiac surgeons from Beth Israel Lahey Health, provide exceptional medical care in compliance with all applicable Medicare requirements “.

In a statement, Bruce Johnston, chairman of the board, praised the leadership of CEO Michael Lauf and his management team and highlighted the upcoming Edwin Barbey Patient Care Pavilion, which he said will house a new center of oncology and will consolidate the hospital’s cardiology programs. and add 32 new medical and surgical beds to meet demand.

“While it is unfortunate to find ourselves in this situation, the board remains confident and supportive of the leadership of the organization. During Michael Lauf’s tenure, Cape Cod Hospital was repeatedly recognized for excellence in care and significantly improved its operational and financial capabilities. position,” Johnston said. “We look forward to a bright and strong future under the continued leadership of Mike Lauf and his management team.

Richard Zelman is a former Cape Cod Hospital cardiologist who will receive about $4.36 million as a whistleblower in the Medicare case, according to his lawyer.Richard Zelman is a former Cape Cod Hospital cardiologist who will receive about $4.36 million as a whistleblower in the Medicare case, according to his lawyer.

Richard Zelman is a former Cape Cod Hospital cardiologist who will receive about $4.36 million as a whistleblower in the Medicare case, according to his lawyer.

“Largest Settlement Ever Under False Claims Act,” Lawyer Says

Richard Zelman is a former Cape Cod Hospital cardiologist who founded and directed the hospital’s TAVR program. He filed a lawsuit against the hospital in 2022, alleging he was fired after speaking out against what he called the hospital’s unethical practices prioritizing profit over profits. patient care.

Zelman will receive approximately $4.36 million from the settlement as a whistleblower. On his website, Zelman’s attorney, Gregg Shapiro, called the settlement amount “the largest recovery ever under the False Claims Act at a Massachusetts hospital.”

“Dr. Zelman is pleased that the government conducted a thorough investigation and that the case was successfully resolved,” Shapiro said.

What will the Cape Cod hospital have to do?

Cape Cod Hospital also entered into a five-year corporate integrity agreement with the U.S. Department of Health and Human Services, Office of Inspector General, which provides for an annual review of its health care reimbursement claims. Medicare by an independent review body, according to the United States. Law firm.

Cape Cod Healthcare, based in Hyannis, operates two acute care hospitals, Cape Cod Hospital and Falmouth Hospital, as well as a home health and hospice agency, nursing and rehabilitation center qualified, an assisted living center and a number of health programs.

The hospital no longer has a contract with Brigham and Women’s Hospital in Boston, which had been a partner in the Cape Cod hospital’s open heart program since its inception in 2002. The hospital has been affiliated with Beth Israel Lahey Health since 2022.

Zane Razzaq writes about housing and real estate. Contact her at zrazzaq@capecodonline.com. Follow her on @zanerazz.

THE Cape Cod Times provides this coverage free of charge as a public service. Please take a moment to support local journalism by subscribing.

This article originally appeared in the Cape Cod Times: Cape Cod Hospital’s Medicare-claimed bogus heart procedures cost $24 million.

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