Kootenai Health owns and operates Kootenai Medical Center in Coeur d’Alene, Idaho, as well as approximately fifty affiliated clinics and other facilities in Northern Idaho, Washington, and Montana.
The relator worked in Quality Services for Kootenai Health.
Defendant’s Alleged Fraud
The lawsuit alleges that Kootenai Health committed millions of dollars of Medicare fraud, in violation of the False Claims Act (FCA), by:
Fraudulently classified some of its affiliated clinics and facilities as “provider-based,” thereby obtaining higher reimbursement rates;
Billing for services that were actually provided by staff as though they had been provided by physicians;
Admitting inpatients without physicians’ orders;
Inappropriately billing for outpatients as though they had been admitted as inpatients;
Requiring patients to make payments prior to being seen in the ER, in violation of the Emergency Medical Treatment and Labor Act (EMTALA);
Using incorrect diagnosis codes in medical records to avoid Medicare penalties for hospital-acquired conditions; and
Violating various patients’-rights provisions, making the hospital ineligible for Medicare participation.