August 27, 2024
St. Peter’s Health today announced a $10.8 million settlement agreement with the U.S. Department of Justice (DOJ) to resolve an alleged violation of the False Claims Act. The matter involves St. Peter’s self-disclosure of the overpayment of certain claims from various Federal Health Care Programs. These overpayments include healthcare services performed, ordered and referred by Dr. Thomas Weiner, an oncologist who is no longer employed by the health system.
The settlement was reached after St. Peter’s voluntarily filed an initial self-report in December 2020 and a final report in May 2022 to the Centers for Medicare & Medicaid Services (CMS) and the U.S. Office of the Inspector General (OIG) based on concerns identified in an audit of Dr. Weiner’s clinical documentation. CMS reviewed a sample of medical record documentation and payments St. Peter’s received Jan. 1, 2015 – Dec. 31, 2020 from federal payors, based on their protocol of a six-year reporting period review.
Authorities contend that St. Peter’s Health, relying on Dr. Weiner’s medical record documentation and billing certification, submitted claims that were either coded at a higher level of service than was actually performed (“upcoded” claims) or did not meet the requirements of a significant, separately identifiable service (“non-payable” claims). Further, authorities contend that St. Peter’s, relying on Dr. Weiner’s medical record documentation and billing certification, overcompensated Dr. Weiner with a salary that was inconsistent with fair market value which triggered a Stark Law violation.
“We believe this to be an isolated situation,” said St. Peter’s Health Chief Executive Officer Wade Johnson, FACHE. “Acting with integrity is important to us, so the decision to self-report in 2020 was made without hesitation.”
According to Bob Wade, Esq., a health care partner in the national law firm of Nelson Mullins who is nationally recognized for his focus on health care regulatory matters, health systems conduct routine billing audits as a matter of practice, but they trust physicians to accurately document and code for services performed and make medical necessity determinations based on the patient’s medical condition. Billing, as well as physician productivity and compensation, are all generated based on these codes and determinations. In 2023, CMS settled 176 self-reported disclosures nationwide.
“No health system can validate every code a physician enters during a patient encounter against their detailed notes of a patient’s health condition, diagnosis or treatment,” said Mr. Johnson. “Audits are designed to look for consistency, trends and types of coding based on the typical services provided by certain physicians or specialists. False claims and Stark Law violations occur around the country every year, and organizations are encouraged to self-report violations when they discover them.”
In the settlement, St. Peter’s is credited under the Department of Justice’s Guidelines for Taking Voluntary Disclosure, Cooperation and Remediation into Account in False Claims Act Matters. The DOJ noted, “In addition to voluntarily self-disclosing the misconduct, [St. Peter’s] performed and disclosed results on an internal investigation; disclosed relevant documents beyond existing business practices or legal requirement; identified individuals who were aware of relevant information or conduct; made available for interview officers and employees who possessed relevant information; assisted in the determination of the losses caused by the misconduct; and has taken steps to enhance its Corporate Compliance Program.”
“I’m so proud of our medical staff, board members and administration for demonstrating integrity and living their values throughout this difficult and disheartening situation,” said St. Peter’s Health Board Chair George “Russ” Bell, Ph.D. “Our community is fortunate to have people who care so deeply and will do the right thing.”
Johnson acknowledged this is a significant financial settlement and it will be paid out of reserves. No donor funds will be used. The organization is focused on moving forward and will continue to invest in its people and the community. “St. Peter’s is ultimately responsible for maintaining compliance with federal law, and our team has worked hard to ensure we have a much stronger compliance program in place today,” said Johnson.
St. Peter’s corporate compliance program has oversight of the coding and billing generated from medical record documentation. The program has been restructured to strengthen the organization’s compliance practices including appointing a new Corporate Compliance Officer and Committee; implementing a more frequent and robust process to monitor documentation practices and quality measures; establishing a committee to conduct more rigorous audits of physician contracts and compensation; and increasing employee compliance education and training. St. Peter’s also transitioned from post-bill to pre-bill audits, which allow the billing and coding team to proactively flag anomalies and work with providers to educate and adjust charges in the billing system. In 2021, St. Peter’s was recognized as the first hospital in Montana to earn the prestigious ISO-9001 certification for demonstrated achievement in processes for patient care, billing, and other critical aspects of running a modern hospital. The recent investment in Epic’s best-in-class technology further streamlines the organization’s operational and compliance processes.
St. Peter’s has also continued to expand its cancer care program, affiliating with the world-renowned Huntsman Cancer Institute at the University of Utah in 2021. That same year, St. Peter’s launched a Specialty Pharmacy program which improves the delivery of oral chemotherapy treatments that patients can take at home. In 2022, St. Peter’s welcomed Medical Oncologist and Hematologist Dr. Elizabeth Bigger and Oncology and Hematology Nurse Practitioner Melissa Cotner, who joined Radiation Oncologist Dr. Andrew Cupino in St. Peter’s Health Cancer Care.
“Our patients trust us with their health and well-being, and it’s a privilege and responsibility we take very seriously,” said Johnson. “St. Peter’s is committed to serving our patients and providing the great care and experience our community deserves.”