Medical societies take on OIG over PATH audits

With neither side showing signs of backing down, the legal battle between federal health care investigators and a coalition of major medical associations over the government's controversial Physicians at Teaching Hospitals (PATH) audit initiative is set to escalate a week from today.

On April 27 in Santa Ana, CA, oral arguments will begin in a lawsuit filed by the Chicago-based American Medical Association and other groups against the HHS Office of the Inspector General in an attempt to end the PATH initiative as it is currently being conducted. Meanwhile, the Greater New York Hospital Association, based in New York City, is only days away from filing a similar lawsuit against the federal government over pending PATH audits in New York State.

There are good reasons why the hospitals are digging in their heels. Only last month, the fourth PATH investigation was settled when the University of Pittsburgh School of Medicine agreed to pay the government $17 million to avoid long and costly litigation over alleged violations of the False Claims Act. (See related story on the settlement, below right.)

Until the Pitt settlement was announced, some had hoped that federal investigators were backing away from the PATH initiative, which is designed, in part, to investigate teaching institutions at which physicians claim Medicare Part B reimbursement for services actually rendered by residents. (See related story on how to avoid a PATH audit, page 3.)

Last year, the Department of Health and Human Services revised its PATH policy, saying it would not prosecute institutions served by carriers that had provided inadequate guidance on PATH reimbursement rules. Because of that new policy, the department dropped 16 of 49 academic health centers from its investigation.

The AMA welcomed the PATH revisions but notes that after eliminating the 16 teaching institutions from its investigation, the government announced plans to add 20 or 30 more this year. Currently, 39 institutions are being targeted by PATH investigators, according to the OIG.

Five of those institutions are in New York State, where the Greater New York Hospital Association is filing a suit of its own against the government for its handling of the PATH initiative. Susan Waltman, JD, the association's general counsel, says the basis of the suit is the government's reliance on the clarity of documents provided to hospitals by local carriers.

"You can't have local carriers setting policy without the federal rule-making process," Waltman says. She adds that because the federal government's guidelines themselves are unclear, teaching hospitals are being investigated for things that have less to do with fraud than with misunderstandings over how claims are documented. "A great deal of this gets down to nothing more than documentation and whether a counter-signature is an acceptable means of demonstrating physician presence." Both suits come only a month after the most recent big-money PATH settlement in Pittsburgh.

The AMA's suit, filed in October 1997, also includes as plaintiffs the Washington, DC-based Association of American Medical Colleges (AAMC), as well as 13 academic organizations and 30 medical societies.