top of page

UPMC, affiliates agree to pay $2.5 million in false claims settlement

Starting in 2006, UPMC’s neurosurgical practice enjoyed “astonishing” growth, becoming the single highest-grossing physician group of its kind in the nation, according to a lawsuit filed in U.S. District Court.

Fueled by neurosurgical revenue, UPMC Presbyterian was the top-grossing acute-care hospital in the country in 2009, the lawsuit alleges, citing Medicare data. But a big part of the success came from doctors performing more complicated and costly operations than were necessary, fraudulent billing and charging for care that was not rendered, according to the lawsuit, which was filed by two surgeons and a surgical technician.

The three-count False Claims Act lawsuit was disclosed Monday after being filed under seal in 2012 against the health system giant by neurosurgeon William Bookwalter, retired neurologist Robert Sclabassi and Presby surgical technician Anna Mitina. The Justice Department announced a settlement Wednesday with UPMC, which requires UPMC and three affiliates to pay $2.5 million to settle civil claims that were outlined in the whistleblower lawsuit.

In addition to UPMC, University of Pittsburgh Physicians Inc., UPMC Community Medicine Inc. and Tri-State Neurosurgical Associates-UPMC were part of the agreement.

In a written statement, UPMC said the doctors themselves did not submit the false bills to Medicare and other government agencies and the hospital giant conducted an internal review and reported the errors to the U.S. Attorney’s office when they were discovered. UPMC did not admit any liability in the settlement and said it would defend itself “vigorously” if the whistleblowers proceed with the case.

Such lawsuits allow whistleblowers to sue for treble damages and the lawsuit alleged that UPMC improperly billed the government tens of millions of dollars between 2006 and 2015. The Justice Department decided not to intervene further, but the U.S. Attorney’s office in Pittsburgh indicated that the plaintiffs would continue to pursue other aspects of the case, which are still under court seal.

Drs. Bookwalter and Sclabassi were not available, Ms. Mitina could not be reached. Lawyers for the plaintiffs did not return calls.

The 2012 complaint outlines a culture among UPMC surgeons in which the number of procedures performed outweighed patient safety. The system’s neurosurgeons, who specialize in diseases of the spine and brain, were paid bonuses totaling hundreds of thousands of dollars per year if they exceeded an annual base workload, the lawsuit alleges. At monthly meetings, former neurological surgery department chair Amin Kassam “openly exhorted” doctors to increase their surgical volume, financially benefiting the health system and the doctors individually, according to the lawsuit.

As a result, the amount that the surgeons billed grew at an “astonishing rate,” with “individual neurosurgeons performing at what can only be characterized as super-human levels,” the lawsuit said. The achievement would not have been possible without a strategy of inflating bills for medical procedures.

Complex surgical procedures have a higher reimbursement than simpler, outpatient procedures, so to reach these numbers, and “with full knowledge and endorsement of UPMC’s administration, certain of the physicians have engaged in a pervasive pattern of performing medically unnecessary and/​or more complex surgeries when simpler and safer procedures were the standard of care,” according to the 2012 lawsuit that UPMC settled with the Justice Department’s announcement Wednesday.

Based on the number of spinal surgeries performed in 2008, UPMC “knowingly submitted tens, and possibly hundreds, of millions of dollars in fraudulent billings to Medicare and Medicaid for reimbursement based solely on lack of medical necessity,” the lawsuit said.

Pumping up revenue for the doctors also included surgeons routinely booking themselves as assistants in simultaneous overlapping operations by spending very little actual time in the operating room at UPMC Shadyside and Passavant hospitals, the complaint alleges, creating “first assistant phantoms” and allowing doctors to bill Medicare for the service.

Teaching hospitals receive extra reimbursement for training new doctors, but supervising doctors were not always immediately available in the operating room as required by Medicare, the lawsuit said. In fact, physician residents and sometimes even physician assistants perform “complicated neurological procedures without the supervision, involvement or physical presence of an attending/​teaching physician,” the plaintiffs alleged.

“Indeed, as late as May 2015, patients have undergone spinal surgeries that were performed by a physician assistant without the supervising physician present in the operating room,” according to the lawsuit. Although they were not immediately available to help if needed, teaching physicians received full work credit for procedures performed by other, less experienced medical professionals.

Another strategy used to pump up doctor income and revenue for the institution was to bill for more complex surgical procedures than were actually done, a practice called upcoding, according to the lawsuit. One surgeon, who was not identified, alleged that he found three cases where a UPMC neurosurgeon billed Medicare for procedures that he later discovered were not done.

“I can no longer remain silent to such activities going on within our profession, our community and our hospital,” the doctor complained in a letter to Shadyside hospital officials.

Kris, or 412-263-1699; Torsten, or 412-944-6551

620 views0 comments
bottom of page