On January 4, 2010, the DOJ announced a settlement with Wheaton Community Hospital and Dr. Stanley Gallagher pursuant to which the hospital and physician will pay almost $850,000 to resolve allegations that the hospital admitted some patients and kept other patients admitted “when doing so was not medically necessary.” http://justice.gov/opa/pr/2010/January/10-civ-001.html The case began as a whistleblower action filed by a physician who had previously practiced at the hospital with Dr. Gallagher. The whistleblower physician will receive $203,000 as his share of the settlement.
This case should serve as a reminder to hospitals to ensure that their utilization review departments are verifying that hospital admissions and continued inpatient stays are reasonable and medically necessary. Health care providers are responsible for ensuring that their billing practices are consistent with Medicare, Medicaid and other payor guidelines. When billing practices fall out of compliance and either go undetected or are ignored, such circumstances are ripe for whistleblower lawsuits.