United States v. Mount Sinai Hospital

256 F. Supp. 3d 443, 2017 U.S. Dist. LEXIS 85007
CourtDistrict Court, S.D. New York
DecidedMay 16, 2017
Docket13 Civ. 4735 (RMB)
StatusPublished
Cited by6 cases

This text of 256 F. Supp. 3d 443 (United States v. Mount Sinai Hospital) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States v. Mount Sinai Hospital, 256 F. Supp. 3d 443, 2017 U.S. Dist. LEXIS 85007 (S.D.N.Y. 2017).

Opinion

DECISION & ORDER

RICHARD M. BERMAN, U.S.D.J.

I. Background

This Decision <& Order resolves the summary judgment motion, dated October 19, 2016, of Mount Sinai Hospital, Mount Sinai School of Medióme, and Mount Sinai Radiology Associates (collectively, “Defendants”), to dismiss the claims of Xiomary Ortiz and Joseph Gaston (collectively, “Plaintiffs” or “Relators”) under the qui tarn provisions of the False Claims Act, 31 U.S.C. §§ 3729, et seq. (“ECA”) and the New York State False Claims Act, N.Y, State Finance Law §§ 187, et seq. (“NYSFCA”).1

Mount Sinai Hospital provides, among other medical services, inpatient and outpatient radiology. (Defendants’ Statement of Undisputed Material Facts, filed Oct. 19, 2016 (“Defs.’ 56.1”), ¶ 1.) Plaintiffs’ allegations in this action relate to billing for outpatient radiology services. (Id. ¶ 3.)

Between 2007 and 2011, Mount Sinai Radiology Associates had a Billing Department which submitted bills to Medicare and Medicaid for outpatient radiology services provided to patients. (Id. ¶ 2.) Plaintiff Ortiz worked in the Radiology Associates’ Billing Department from early 2007 until early 2011. (Id. ¶ 16.) Plaintiff Gaston has not worked in the Billing Department. (Defs.’ 56.1 ¶ 17.) On February 1, 2011, Mount Sinai outsourced the Radiology Associates’ billing function (for outpatient radiology services) to McKesson Corp., a third-party billing service. (Id. ¶ 7.)

Daniel Dorce was the Billing Manager of Radiology Associates’. Billing Department until he resigned in August 2010. (Defs.’ Reply and Response to Relators’ Counter-Statement of Material Facts, filed Dec. 16, 2016 (“Defs.’ Reply 56.1”), ¶¶ 6, 40.) The parties agree that, during his tenure as Billing Manager, “Dorce and other staff members created and used lists they called ‘cheat sheets’ for the purpose of identifying in advance which radiologists they would list on [Medicare and Medicaid] claims forms as the rendering physician — regardless of who the actual rendering physician was.” (Id. ¶ 13 (emphasis added).) Billing. Department employees “were specifically instructed by Daniel Dorce to bill payers [such as Medicare and Medicaid] under a participating physician[’s] name only.”2 (Schwartz Deck, filed Oct. 19, 2016, Ex. 17B at 2.) “So if a non-par[ticipating] physician had actually performed the procedure, [employees] [447]*447were instructed not to utilize his/her name for billing purposes but to ... refer to [Dorce’s] list and ch[oose] a participating physician and bill under his/her name.” (Id.)

Defendants concede that, at Dorce’s instruction, there were “instances in which Outpatient Radiology Billing ... misidentified staff radiologists on bills to Medicare or Medicaid, both rendering” radiologists (i.e. those who performed the radiological service) and “referring” or “ordering” radiologists (i.e. those who directed the patient to see another radiologist). (Defs.’ 56.1 ¶ 34); see also id. ¶¶ 21-23; Hr’g Tr. before Magistrate Judge Moses, dated Aug. 18, 2016, at 49:25-50:5 (Defendants stipulated, for example, that “[t]he Mt. Sinai outpatient radiology Billing Department submitted claims to Medicaid that identified Drs. Jaime Lopez-Santini and David C. Thomas, as the referring physicians when the referral was provided by a different attending or teaching physician”).

On March 3, 2011, the Mount Sinai School of Medicine voluntarily disclosed in a letter to the Office of the Medicaid Inspector General (“OMIG”) that the Medicaid enrollment of two staff radiologists had (only) been pending at the time Medicaid was billed for their services, and that both doctors had been misidentified on the submitted claim forms. (Defs.’ 56.1 ¶ 40.) The School of Medicine refunded Medicaid in the amount of $15,012.41 which had been paid by Medicaid even though these two doctors had not completed their enrollment in Medicaid. (Id. ¶ 41.) The letter to OMIG also stated in a footnote the following:

[W]e also [have] identified claims where the Billers randomly substituted the name of one enrolled radiologist with the name of another enrolled radiologist when billing under the group number. Both the rendering radiologist and the listed radiologist were enrolled with the Medicaid Program. Accordingly, we have not included those claims in our refund calculations.

(Schwartz Decl., Ex. 3 at 2 n.1.)

The U.S. Medicare Program Integrity Manual is published by the Centers for Medicare & Medicaid Services, a Federal agency, and “establishes] the roles and responsibilities of the various organizations or units responsible for ensuring the integrity of the Medicare program.” (Relators’ Mem. of Law in Opp. to Mot. for Summ. Judg., filed Nov, 18, 2016 (“Ps,’ Mem.”), at 12 footnote 6.) Section 4.2,1 of the Manual states, “The most frequent kind of fraud arises from a false statement or misrepresentation made, or caused to be made, that is máterial to entitlement or payment under the Medicare program.” (Mclnnis Decl., filed Nov. 18, 2016 (“Medicare Integrity Manual”), Efe 27 § 4.2.1.) A Manual example is “[misrepresentations of ... the identity of the ... individual who furnished the services.” (Id.) CMS 1500, the health insurance claim form used by Medicare'and Medicaid, requires the physician who signs the form to represent that: “In submitting this claim for payment from federal funds, I certify that: ... the services on this form were ... personally furnished by me.” (Mclnnis Decl., Ex. 28.) Under the line, “Signature of Physician (or Supplier),” the individual is also directed to represent: “I certify that the services listed above ... were personally furnished by me.” (Id. (emphasis in original).)

In addition to the instances of mischar-acterization of the rendering and referring physicians mentioned above, Plaintiffs have identified seven (unchallenged) instances in which Radiology Associates’ Billing Department: (1) submitted a claim to Medicare utilizing a billing code that overstated the diagnosis codes, or the pro[448]*448cedure codes (“upcoding”); 3 (2) billed for services not performed (“phantom billing”); 4 or (3) billed (two or more times) for the same service (“multiple billing”).5 (Defs.’ Reply Mem. of Law. in Supp. of Defs.’ Mot. for Summ. Judg., filed Dec. 16, 2016 (“Defs.’ Reply”), at 11 & n.10.)

On November 3, 2010, Plaintiff Ortiz submitted to Defendants’ Auditing Department a statement describing the Radiology Associates’ Billing Department’s practice of “switching” radiologists’ names.6 (Schwartz Decl., Ex. 17B at 2.) She contended that the “department was instructed ... by Daniel Dorce to bill for authorized procedures only and not what was actually done.” (Id.) According to Defendants, the Auditing Department investigated Ortiz’s allegations and “found instances in which [Radiology Associates’ Billing Department] had misidentified staff radiologists on bills to Medicare or Medicaid.” (Defs.’ 56.1 ¶¶3, 34.) It also found, as noted supra p. 447, that “the Medicaid enrollment of two staff radiologists had been pending [but not approved] at the time Medicaid was billed for their services.” (Id. ¶ 40.)

As noted above, Mr. Dorce resigned in August 2010. Supra pp. 446-47.

Procedural Background

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256 F. Supp. 3d 443, 2017 U.S. Dist. LEXIS 85007, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-v-mount-sinai-hospital-nysd-2017.