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A whistle-blower lawsuit based on insider information from a former Florida Hospital-Orlando billing employee and a staff physician alleges that seven Adventist Health hospitals in Central Florida have overbilled the federal government for tens of millions of dollars in false or padded medical claims.
The suit claims Florida Hospital used improper coding for more than a decade to overbill Medicare, Medicaid and Tricare, all federal government payors. In addition, it alleges, the hospital commonly overbilled for a drug used, for example, in MRI scans and billed for computer analyses that were never performed.
Plaintiffs Amanda Dittman, a bill-coding and reimbursement compliance officer, and Dr. Charlotte Elenberger, a radiologist, were either employed or affiliated with Florida Hospital Orlando between 1995 and 2009. They filed a lawsuit in July 2010, alleging that the improprieties occurred during those years.
Last week their suit received a green light from U.S. District Judge John Antoon to proceed. In his ruling, Antoon denied Adventist Health System's motion to dismiss the claim, calling the evidence "extensive and sufficient."
Adventist Health, based in Altamonte Springs, asked the judge to dismiss the case for insufficient evidence. However, Antoon refused the request, saying the complaint "satisfies the [False Claim Act] requirements of describing the alleged fraudulent acts, why they were fraudulent, when they occurred, and who engaged in them."
Among the Florida hospitals cited are Florida Hospital Orlando, Florida Hospital Altamonte, Florida Hospital Apopka, Florida Hospital East Orlando, Florida Hospital Celebration Health, Florida Hospital Kissimmee and Winter Park Memorial Hospital.
In February, four local Adventist Health hospitals paid $3.9 million to the federal government to settle allegations that they overbilled Medicare.
'Could exceed $100 million'
Marlan Wilbanks, attorney for the plaintiffs, said that, although he can't determine the total amount of damages until he gets sworn depositions and gathers more records, "we know the sum is very large because it went on for over a decade."
If found guilty, the health system would not only be responsible for repaying the excess money received, but also for paying civil penalties of $5,500 to $11,000 per false claim, and damages, he said.
"When you're looking at something that happened thousands of times, and that carries substantial civil monetary penalties for each claim and treble damages, the total exposure could exceed $100 million," Wilbanks said.
A trial is set for December 2013.
Gabriel Imperato, attorney for Adventist Health, would not discuss the case, saying, "It is our policy not to comment on pending litigation for our clients."
Hospital spokeswoman Samantha O'Lenick said that, although she was aware of the case, "we don't comment on any cases that are in active litigation."
Dittman worked for Florida Radiology Associates from 1996 to 2001 and then for Florida Hospital Orlando from 2001 to 2008. During that time, the lawsuit alleges, she witnessed billing-code "modifiers" routinely misused in ways that would result in extra payments.
"This allegation is not limited to Florida Hospital Orlando," said Wilbanks, but extends to the other hospitals named in the suit. Dittman ultimately had billing responsibilites in each of the hospital's radiology departments.
Dittman also alleged that the hospital routinely used a billing code for a larger dose of the drug octreotide than was actually administered. A radioactive agent given intravenously or by injection, octreotide is used to enhance radiology images. Rather than bill for 1,000 micrograms of the drug, it billed for 5,000 micrograms, the suit alleges, overcharging the government by nearly $2,500 per dose.
While working for Florida Radiology Associates from 1995 to 2008, Elenberger had staff privileges at Florida Hospital Orlando and alleges the hospital was billing — and being paid — for services related to a computer-aided-detection analysis that helps doctors interpret mammography scans, even when the CAD analysis wasn't performed.
For three months in 2006 the CAD system wasn't working, yet the hospital billed for the CAD scans, the suit alleges.
Taxpayers recover
Under the False Claims Act, whistle-blowers stand to gain substantial amounts, sometimes as much as 10 percent to 20 percent of the award, experts say. However, coming forward with knowledge of fraud is "always difficult for health-care professionals," Wilbanks said. It can be career-limiting.
Since filing suit, Elenberger continues to practice in Central Florida, although in Nov. 2009 she chose to resign her staff privileges at Florida Hospital. Dittman now works for a hospital in California.
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