Widow, doctor blew whistle on SIUH

The $89 million settlement by Staten Island University Hospital (SIUH) was prompted when two people — one the widow of a cancer patient and the other a doctor who saw improper billing — sounded the alarm through lawsuits filed under the False Claims Act (FCA).

Elizabeth M. Ryan, widow of an SIUH cancer patient, asserted in her federal FCA suit that SIUH fraudulently billed Medicare for stereotactic body radiosurgery treatment that was provided on an outpatient basis to cancer patients. She originally pursued a malpractice claim, but then filed a qui tam lawsuit when questions arose about billing for the treatment. The investigation established that from 1996 through 2004, SIUH defrauded Medicare and TRICARE by knowingly using incorrect billing codes for cancer treatment performed at the hospital. By using incorrect codes, SIUH obtained reimbursement for treatment that was not covered by Medicare or TRICARE. SIUH will pay the United States $25,022,766 to settle the claim, according to an agreement that has been approved by U.S. District Judge John Gleeson, JD.

States that have enacted False Claims Acts

Of the 13 state laws creating their own False Claims Acts (FCAs), some have been approved by the federal government and some have not. Approval means the states can receive 10% more of the recovery from a federal FCA case than they would receive if they had no state FCA, explains Christopher DeMeo, JD, an attorney with the law firm of McGlinchey Stafford PLLC in Houston.

Even if the state FCA does not meet the federal Office of the Inspector General (OIG) requirements for, however, it still is a valid law that can be enforced by the state. Given the financial incentive to comply with the OIG's requirements, most of the noncompliant laws will likely be redrafted, DeMeo says. Many more states are in the process of enacting their own acts.

These states have created FCA laws that meet the OIG requirements:

  • California
  • Georgia
  • Hawaii
  • Illinois
  • Indiana
  • New York
  • Rhode Island
  • Tennessee
  • Texas
  • Virginia

These states have laws that currently do not comply with the federal criteria:

  • Florida
  • Louisiana
  • Oklahoma

Miguel Tirado, MD, a former SIUH director of Chemical Dependency Services, who filed suit under the federal FCA and the New York State FCA, alleged that the hospital had fraudulently billed Medicaid and Medicare for inpatient alcohol and substance abuse detoxification treatment. The government's investigation established that, during the period July 1, 1994, through June 30, 2000, SIUH submitted claims for payment for detoxification treatment provided to patients in beds for which SIUH had received no certificate of operation from the New York State Office of Alcoholism and Substance Abuse Services (OASAS).

Although SIUH was authorized to provide inpatient detoxification care to patients in 56 beds, it administered treatment in 12 additional beds located in a locked, separate wing and concealed the existence of the wing from OASAS, according to the Justice Department. SIUH has agreed to pay the United States $11,824,056 and $14,883,883 to the state of New York according to an agreement that has been approved by U.S. District Judge Edward R. Korman, JD. New York State's claim was litigated by the New York State Attorney General's Office, Medicaid Fraud Control Unit.

The settlement also concerns SIUH's billings to Medicare and Medicaid for treatment of psychiatric patients in unlicensed beds during the period of July 2003 through September 2005. The hospital has agreed to pay the United States $1,478,989 to settle this claim.

The federal FCA and newly enacted New York state FCA permit private individuals to file suits on behalf of the government and receive a portion of the recovery.

As a result of the settlement, Tirado will receive $2.3 million from the federal government and $2.97 million from New York. Ryan will receive $3.75 million as her portion of the federal recovery.

The government's other two claims were resolved prior to the filing of suit. The United States had determined that SIUH deliberately inflated its resident count from the 1996 cost report year through the 2003 cost report year. Medicare pays a share of the cost of Graduate Medical Education at teaching hospitals such as SIUH. The amount paid is determined by Medicare annually based upon "cost reports" submitted by the hospitals. SIUH has agreed to pay the United States $35,706,754 to settle this claim.