Cape Cod Hospital to Pay $24.3M for Medicare Rule Violations

Cape Cod Hospital to Pay $24.3M for Medicare Rule Violations

Cape Cod Hospital has agreed to pay $24.3 million to settle allegations that it knowingly filed false claims with Medicare for transcatheter aortic valve replacement (TAVR) procedures. These procedures failed to meet Medicare’s criteria for determining patient suitability.

Beginning in 2015, Cape Cod Hospital began offering TAVR procedures for patients with aortic stenosis, a condition that restricts blood flow from the heart. A TAVR procedure replaces a damaged heart valve with an artificial one. Medicare rules required hospitals to have specified clinical personnel independently examine prospective patients, document the rationale for their clinical judgment, and share it with the medical team performing the procedure.

Between 2015 and 2022, Cape Cod Hospital did not always have enough physicians to assess patient suitability or properly document and share clinical judgments, so the use of TAVR procedures was suspect. As part of the settlement, the hospital agreed to a five-year Corporate Integrity Agreement with the HHS Office of Inspector General, which includes annual Medicare claim reviews.

The claims settled by the resolution include those filed under the qui tam, or whistleblower, provisions of the False Claims Act. This Act allows private individuals to initiate lawsuits on behalf of the United States and receive a share of any financial recovery. As part of the settlement, the whistleblower will receive approximately $4.36 million as a whistleblower reward. Jason T. Brown, CEO of whistleblower law firm Brown, LLC, stated, “This case highlights the critical role of accountability in our healthcare system. Cape Cod Hospital’s failure to follow Medicare rules for TAVR procedures jeopardized patient care and wasted taxpayer money. The settlement demonstrates the importance of maintaining medical standards and the False Claims Act’s effectiveness in combating healthcare fraud. We applaud the whistleblower’s courage and the government’s thorough investigation.”