In full transparency, the following is a press release the U.S. Attorney’s office. Tenet Healthcare, which owns St. Vincent Hospital in Worcester, also owns MetroWest Medical Center in Framingham.
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BOSTON – St. Vincent Hospital (St. Vincent) in Worcester has agreed to pay approximately $1.784 million to resolve allegations that it received impermissible “outlier” payments from Medicare by inflating its charges for cardiac surgical procedures and failed to fully reimburse the government for its receipt of these outlier payments after it became aware of the issue.
As part of the settlement, St. Vincent admits that it received outlier payments to which it was not entitled.
Hospitals performing surgical procedures can receive reimbursement from Medicare by submitting a claim to a Medicare Administrative Contractor containing, among other information, a Diagnosis Related Group (DRG) code that identifies the procedure performed and the hospital’s costs and charges for the services and supplies provided in treating the patient. In some cases, a hospital might report having incurred extraordinarily high costs due to performing medically necessary services to address unforeseen complications for a particular patient. In such cases, where a hospital suffers losses in excess of a set threshold, Medicare will pay a hospital an “outlier” payment, in addition to the set reimbursement amount.
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St. Vincent admits that between 2018 and 2019, it increased its charges for all inpatient services, including for a cardiac surgical procedure known as a Transcatheter Aortic Valve Replacement (TAVR); once by 18%, and two more times by 15%. St. Vincent’s increased charges resulted in a greater number of Medicare outlier payments, including cases where outlier payments were not appropriate because there were no unforeseen complications or extended lengths of stay that led to the extraordinarily high costs.
Although prior to settling with the United States, St. Vincent made a voluntary payment to the Medicare Administrative Contractor, that voluntary payment did not fully reimburse Medicare for all outlier payments St. Vincent received for TAVRs and other cardiac-related surgical procedures in cases where patients did not require an increased level of care or an extended length of stay resulting in extraordinarily high costs.
United States Attorney Rachael S. Rollins and Phillip M. Coyne, Special Agent in Charge of the Department of Health and Human Service’s Office of Inspector General, Boston Regional Office made the announcement today, December 9.
The matter was handled by Assistant U.S. Attorneys Steven Sharobem and Jessica J. Weber of Rollins’ Affirmative Civil Enforcement Unit.
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MetroWest Medical Center