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State investigating hospital billings

By Jim Saunders
9/17/2010 © Health News Florida

The Florida attorney general's office is investigating 18 hospitals, including some of the state's largest, on suspicion of improper Medicaid billing for emergency-room services. Three others have already settled. 

St. Joseph's Hospital in Tampa, Lakeland Regional Medical Center and All Children's Hospital in St. Petersburg agreed in recent months to pay a total of $566,004, while denying any wrongdoing. The attorney general's Medicaid Fraud Control Unit began the investigation in October 2008.

The investigation is closely linked with a dispute between a group of hospitals and the state Agency for Health Care Administration that is pending before an administrative law judge. That dispute, in part, involves Medicaid reimbursements when patients go to emergency rooms but don't truly need emergency treatment.

Joanne Erde, an attorney for the group of hospitals, said she thinks the two sides in the AHCA case are close to an agreement that would prevent the need for an administrative hearing and could affect the attorney general's investigation.

The investigation centers on whether hospitals used an incorrect billing code to get reimbursed for emergency-room services. The correct billing code is important because it helps determine how much Medicaid pays hospitals -- and whether they get paid too much.

While most details of the ongoing investigation have not been released, attorney general's spokeswoman Ryan Wiggins said in an e-mail that the Medicaid Fraud Control Unit is "examining the issue of submission of false claims for payment as it relates to patient screening and/or non-emergency services.'' Patient screening involves initial exams that people receive when they go to emergency rooms.

Lakeland Regional agreed in April to pay $108,504 after the state initially sought damages of as much as $5 million, said Paul A. Powers, vice president of finance and chief financial officer. Continuing the case could have led to larger legal fees.

"Our decision to settle it was to get it behind us,'' Powers said. "We felt that, really, the state did not have an issue.''

The agreements include language in which St. Joseph's, Lakeland Regional and All Children's deny that they "knowingly submitted any claims in violation of state or federal law.'' The documents also indicate the settlements were reached to avoid the time, uncertainty and expense of lengthy litigation.

St. Josephs, which finalized its settlement in August, agreed to pay $357,500 to the state, while All Children's agreed in July to pay $100,000. The other 18 hospitals under investigation are scattered throughout Florida and include such big names as Jackson Memorial in Miami and Tampa General, according to a list from the attorney general's office. 

The investigation has been going on at the same time that a group of 10 hospitals battles legally with the Agency for Health Care Administration about emergency-room reimbursements. AHCA spokeswoman Tiffany Vause said the agency would not discuss details amid the continuing litigation and negotiations.

Hospitals have filed three administrative challenges since June 1 against the agency. The challenges have been consolidated into one case that was scheduled to go to a hearing next week, though it was unclear Thursday whether the hearing will be held because of the negotiations.

Part of the dispute centers on a $24 fee that AHCA has set to reimburse hospitals for the initial screening of emergency-room patients. On top of that, hospitals argue AHCA is improperly trying to deny payment for outpatient-like services provided to ER patients who are not deemed in the screening process to need emergency care.

The dispute plays out in billing codes. The $24 fee is in one code; hospitals receive more money through another code that covers needed emergency treatment.
Hospitals contend that AHCA has not followed proper legal procedures in making its payment decisions and that the moves have led to lower reimbursements than hospitals should receive.

Beth Kidder, chief of AHCA's Bureau of Medicaid Services, said during a recent meeting that the agency is trying to spur the use of ER alternatives, such as walk-in clinics, when Medicaid patients do not need emergency care.

"The agency is committed to providing care in the most appropriate setting and believes that when that goal is met, care is typically less expensive and more effective,'' Vause said in an e-mail last week.

The hospitals that are still under investigation were identified by the Attorney General's office as:

1. Munroe Regional Medical Center - Ocala

2. Holmes Regional Medical Center Inc - Melbourne

3. Southwest Volusia Healthcare Corp - Orange City

4. Wuesthoff Memorial Hospital Inc - Rockledge

5. Baptist Hospital Inc - Pensacola

6. Bay Medical Center - Panama City

7. Southern Baptist Hospital of Florida - Jacksonville

8. Tallahassee Memorial Healthcare Inc

9. Naples Community Hospital

10. Lifemark Hospital of Florida,

11. Lee Memorial Health System

12. Miami Children's Hospital

13. Baptist Hospital of Miami

14. Homestead Hospital Inc.

15. Jackson Memorial

16. Memorial Regional

17. Broward General Medical Center (Clarification: an earlier version of the list provided by the Attorney General's Office implied the entire North Broward Hospital District was under investigation; that is not so.)

18. Tampa General

--Capital Bureau Chief Jim Saunders can be reached at 850-228-0963 or by e-mail at jim.saunders@healthnewsflorida.org.