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UPMC waves off agreement that would bring 5 years of federal tracking

Pittsburgh, PA (March 23, 2023) - As part of an $8.5 million settlement with the government involving allegations of fraud against a star surgeon, UPMC was offered the chance to enter into an agreement to head off future Medicare billing problems.


The U.S. Department of Health and Human Services Office of Inspector General offered UPMC a Corporate Integrity Agreement, a standard practice for years for doctors and hospitals accused of Medicare billing violations. Most providers sign the agreements to lessen the risk of being expelled from participating in Medicare and other government-run health insurance programs.


In an unusual move, UPMC declined to sign.


The refusal prompted the Office of Inspector General to add the names of UPMC and Dr. James Luketich, longtime chair of its Department of Cardiothoracic Surgery, to a “high risk” list of entities marked for extra government scrutiny “because they pose a significant risk to federal health care programs and beneficiaries,” according to OIG.


The “high risk” designation can last several years until the Office of Inspector General closes the case after beefed up monitoring of the health care facility.


Asked about the decision, UPMC spokesman Paul Wood said signing the agreement wasn’t necessary because the Pittsburgh-based health system had already agreed to audit the surgeon’s Medicare claims for a year.


“The settlement was negotiated in good faith and agreed to by UPMC, Department of Justice and OIG, which put in place a carefully tailored corrective action plan for Dr. Luketich and an agreement for audits of Dr. Luketich’s bills to Medicare for one year,” Mr. Wood said in a statement.


The corporate integrity agreement would have expanded the government’s oversight to five years.


Most doctors are eager to sign such agreements, which typically require regular reporting and internal audits of medical claims for payment that are submitted to the government, said Alice Gosfield, principal at the Philadelphia health care law firm of Gosfield & Associates PC, who was not involved in the UPMC case. Entering into one may lessen the risk of expulsion from government health insurance programs, including Medicare. In 2022, the program accounted for 48% of UPMC’s gross patient revenue.


“The basic point is that the government is going to live out of your wallet and in your office for the next five years. It’s tedious, annoying,” said Ms. Gosfield.


But most health care providers see it as a path to keep in the government’s good graces, she said.


The U.S. attorney in Pittsburgh declined to release the specifics of the agreement offered to UPMC. They are typically written in boilerplate language with specifics tailored to the individual institution.


Such agreements usually require health care providers to implement or expand a comprehensive employee training program, create a confidential way for employees to disclose improper billing or other questionable practices, and designate a compliance officer if these measures have already been taken.


Once such language is approved, failure to comply can result in government penalties.


In fiscal 2021, the federal government opened 831 criminal health care fraud investigations in the U.S. and won more than $5 billion in settlements. None of the doctors or medical groups involved in the settlements that year refused to sign an agreement, according to the Office of Inspector General. Only one physician or medical practice has declined annually since 2018.


In a 2021 lawsuit filed by the U.S. attorney in Pittsburgh, Dr. Luketich was accused of regularly performing as many as three complex surgical procedures at the same time while failing to participate in “key and critical” parts of the operations as required by Medicare. The result pumped up billings for the procedures in a practice that was “well known to UPMC leadership” and increased the risk of surgical complications to patients, according to the government.


Prosecutors said the complications included amputations — part of a hand in one case and a lower leg in another.

As part of the recent settlement, UPMC did not admit to any wrongdoing, although the settlement was not an exoneration.

In the realm of Medicare false claims settlements, $8.5 million is not a big deal, Ms. Gosfield said, and UPMC may have reasoned that the risk of future problems with the government was small, so signing the agreement was low risk.


The lawsuit against UPMC was born out of a whistleblower complaint by a former colleague of Dr. Luketich, and Ms. Gosfield said such cases are a bigger worry for health systems’ than extra government oversight because of the costly impact they can have on an institution in litigation and other expenses.

UPMC faces a second whistleblower lawsuit in the fall. A jury trial is scheduled for October in federal court for a lawsuit that alleges inflated Medicare and Medicaid billings by seven neurosurgeons. The lawsuit, which will be heard by U.S. District Court Judge Cathy Bissoon, seeks damages of $61.4 million, which will be automatically trebled if the plaintiffs prevail.


“The government is the least of your worries,” Ms. Gosfield said. “It’s the whistleblower that you have to worry about.”


By: Kris B. Mamula: kmamula@post-gazette.com Pittsburgh Post-Gazette


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