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本文为大家推荐的是来源于《洛杉矶时报》的一篇文章——Justice Department accuses Ontario-based hospital

chain of cheating Medicare system 作者是 Paul Sisson.

文章内容：

The U.S. Justice Department has joined a whistle-blower case against Prime

Healthcare Services, adding significant weight to allegations of widespread

Medicare overbilling at 14 of the company’s hospitals in California.

A Los Angeles magistrate judge granted the agency’s request to intervene in

the case Tuesday, one day after the government declared in a court filing that

its investigation of the Ontario- hospital operator has “yielded sufficient

evidence” that the facilities “submitted or caused the submission of claims to

Medicare for unnecessary inpatient stays.”

Prime finds itself under federal scrutiny because of a whistle-blower

complaint submitted in 2011 by Karin Berntsen, a registered nurse and director

of quality and risk management at Alvarado Hospital in San Diego. Berntsen’s

lawsuit accuses Prime of routinely making Medicare patients’ illnesses seem more

severe than they really were in order to justify billing for additional services

and increasing hospital admissions.

Berntsen alleged that this practice occurred not only at Alvarado but also

at 13 other Prime properties. Most of these hospitals are in Southern

California, including Centinela Hospital Medical Center in Inglewood, Encino

Hospital Medical Center, Sherman Oaks Hospital and Huntington Beach

Hospital.

Berntsen’s litigation estimates the total amount of overbilling at $50

million, an amount that now could result in a significant financial payoff for

her — and potentially large damages against the company.

Anti-fraud statutes allow fines of $5,500 to $11,000 — plus triple damages

under certain circumstances — for each false or inaccurate bill submitted by

hospitals and other healthcare companies. Whistle-blowers are entitled to 15% to

25% of the money recovered in cases involving the Justice Department.

In 2012, for example, pharmaceutical giant GlaxoSmithKline agreed to pay $2

billion to the federal government to resolve accusations that it overbilled for

the prescription drugs Paxil, Wellbutrin and Avandia. In 2006, Tenet Healthcare

was crippled after paying $900 million in a case involving alleged Medicare

bill-padding, kickbacks and changing of billing codes to obtain higher

reimbursements.

Prime has denied Berntsen’s allegations, calling them “speculative

nonsense” after her complaint was unsealed in 2013.

In a new statement issued after the federal government’s intervention, the

company was a bit more subdued. It said Medicare billing is complex and that

there is a “lack of clarity between what federal regulators and physicians

believe is necessary to adequately document medical necessity for hospital

admissions.”

Prime also said its hospitals have successfully undergone Medicare billing

audits conducted by an array of organizations, including the Joint Commission,

the Healthcare Facilities Accreditation Program, the California Department of

Public Health and government “recovery audit” contractors who are rewarded for

spotting billing irregularities. The company currently owns 43 hospitals across

14 states.

“Over 600 medical records that were appealed to the Administrative Law

Judges and Medicare Appeals Council, all had rulings in Prime Healthcare’s

favor, with no exception,” Prime’s statement said. “Given this precedence of

successful appeals on thousands of claims, Prime Healthcare is confident it will

prevail and ultimately be exonerated.”

But the Justice Department in a wide-ranging investigation referenced in

its court filing this week cited "multiple witnesses who have worked at

different Prime hospitals” who told the government that Dr. Prem Reddy, Prime’s

chairman, president and chief executive, criticized emergency department

physicians and demanded “their termination if he decided they were passing up

opportunities to cause the admission of Medicare beneficiaries.”

The agency said those witnesses also accused Reddy of requesting “increased

work schedules for [emergency department] doctors whose patients had a

relatively high rate of admission,” of decreasing or discontinuing such shifts

for physicians with low rates and of telling emergency department doctors “to

find a way to admit all patients over 65 because they all have insurance.”

In contrast, the government said, Reddy allegedly worked to minimize

hospital stays for uninsured patients — instructing that they should stay in the

emergency department for only six to eight hours to get test results and then be

discharged.

The Justice Department also cited the results of a Medicare contractor’s

review of the company’s hospital admissions that “put Prime on notice of the

same pattern of seemingly unnecessary inpatient admissions.”

Kathleen Clark, a Washington attorney who is an expert on the False Claims

Act that governs whistle-blower cases, said the government’s involvement raises

the stakes, given that federal regulators participate in only about one-quarter

of such cases.

“It is actually quite significant when the government decides to intervene

in one of these cases. The government brings to bear significant investigatory

resources and leverage,” Clark said. “Intervention is seen not as a guarantee of

a win, but it’s a very good sign for the whistle-blower and [his or her]

lawyers.”

Marlan Wilbanks, an Atlanta attorney who is one of several lawyers

representing Berntsen, said the government's involvement could turn up

additional evidence in the case disproving Prime’s assertion that previous

audits proved the company’s billing practices are sound.

“Those entities were not designated to look for fraud," he said. "Prime was

given the benefit of the doubt. However, those entities did not have the

evidence and the documents that the government and [Berntsen’s party] now

possess.”

It’s unclear how long the legal discovery phase might take, especially

because the Justice Department’s intervention will likely spur a series of

procedural adjustments in the case, which is being fast tracked before

Magistrate Judge Patrick J. Walsh.

(原文链接：http://www.latimes.com/business/la-fi-prime-healthcare-20160525-snap-story.html)

以上就是文章全文了，文章来源于《洛杉矶时报》，《洛杉矶时报》是美国西部最大的对开日报，被称为美国的第三大报。文章讨论的是社会类话题，小伙伴们可以先练习阅读文章，归纳文章的论点和中心思想以及文章中作者使用的分析论技巧，最后就是尝试着写作。

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