UPMC may face whistleblower claims that it violated Stark Law and the False Claims Act in its dealings with neurosurgeons once again, after the claims was initially dismissed.
Six things to know:
1. Whistleblowers filed a suit in 2012 alleging UPMC, Pittsburgh Physicians — which UPMC owns — and neurosurgeons submitted false claims to Medicare and Medicaid, and the government intervened in the claims against the physicians, which were settled four years later for $2.5 million. The government did not intervene in the hospital service claims.
2. After the initial government intervention, the whistleblowers filed claims that UPMC and Pittsburgh Physicians submitted false claims and knowingly made false records that resulted in reimbursement from Medicare and Medicaid.
3. The whistleblowers alleged that the health system's contract with surgeons incentivized surgeons to maximize their work relative value units so the surgeons reported performing higher volumes and more complex procedures. From 2006 to 2009, the UMPC neurosurgery department more than doubled wRVUs billed.
4. Whistleblowers also alleged surgeons reported assisting in surgeries and served as teaching physicians when they did not. They also alleged surgeons performed "medically unnecessary" or "needlessly complex" procedures to boost the wRVUs with UMPC's knowledge.
5. The District Court previously dismissed the suit, but the Third Circuit reversed that decision on appeal. Third Circuit found that there were enough facts to move forward with the whistleblowers' allegations, stating: "The relators' complaint alleges enough facts to make out their claim. The surgeons' contracts make it very likely that their pay varies with their referrals. And the relators also make a plausible case that the surgeons' pay is so high that it must take referrals into account."
6. The Third Circuit also found that UPMC and Pittsburgh Physicians should bear the burden of pleading Stark Act exceptions, noting: "And if that burden lay with the relators, their pleadings meet that burden here."