The Duke University Health System agreed to pay $1 million to settle a whistleblower case involving its cardiac services.
The Durham, N.C.-based Duke system was charged with billing for services by physician assistants during CABG procedures and increasing billing by unbundling claims. The suit, filed under the False Claims Act, claimed that the physician assistants were serving as surgical assistants, which the government argued is not allowed in its regulations, and that unbundling for cardiac and anesthesia services was inappropriate.
The federal government stepped in on March 14 in a whistleblower case filed on Dec. 31, 2012, by Leslie Johnson, a former employee at Duke Patient Revenue Management Organization. The university system controlled the office, which handled billing, collection and administrative services. Johnson worked there as a coding supervisor and a quality control auditor between Nov. 4, 2008, and May 14, 2010.
Johnson’s suit claimed that the health system and revenue management office “systematically unbundled services that are required to be bundled, including regularly adding Modifier 59 where it was not applicable; (2) falsely billed for ‘split/shared’ services under a physician's identification number when the services were provided exclusively by a resident; (3) falsely billed for the presence of physician assistants at coronary bypass surgeries when they were present only at a related vein harvesting procedure; (4) billed consultation services as E/M [evaluation and management] services using an automatic crosswalk feature in Defendants’ coding software when the E/M codes billed did not correspond to the services actually performed; (5) systematically used so-called ‘explosion code’ features in Defendants’ coding software to bill separately for services that should be bundled; and (6) billed surgeries performed by physician assistants as if surgeons performed them.”
The suit also claimed the office had retaliated when Johnson tried to stop the practices. The federal government pursued only the claims of unbundling and false billing for physician assistants.
The settlement is not an admission of wrongdoing. “The claims resolved in the settlement are allegations only, and there has been no determination of liability,” the U.S. Attorney for the Eastern District of North Carolina wrote in a statement.