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New Jersey Hospital to Pay $6.35 Million to Resolve Allegations of Inflating Charges to Obtain Higher Medicare Reimbursement

In addition to its standard payment system, Medicare provides supplemental reimbursement, called "outlier payments," to hospitals and other health care providers in cases where the cost of care is unusually high. Congress enacted the supplemental outlier payments system to ensure that hospitals have the incentive to treat inpatients whose care requires unusually high costs. The two lawsuits filed against Robert Wood Johnson University Hospital Hamilton alleged that the hospital inflated its charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid. The United States intervened in both lawsuits in January 2008.

"Taxpayer dollars should go towards quality health care, not wasted on fraud and abuse," said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. "As the settlement announced today demonstrates, the Justice Department is committed to pursuing those who defraud Medicare and drive up the costs of health care."

The two lawsuits were brought under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private citizens with knowledge of fraud against the government to bring an action on behalf of the United States and to share in any recovery. Under the civil settlement announced today, the whistleblowers will receive $1,111,250 of the total recovery.

"This office is determined to protect the integrity of the Medicare system for the citizens of New Jersey and of the United States," said Paul J. Fishman, U.S. Attorney for the District of New Jersey.

Assistant Attorney General West noted that today's settlements was the result of a coordinated effort by the Justice Department's Civil Division, the U.S. Attorney's Office for the District of New Jersey, the Department of Health and Human Services Office of Inspector General and Centers for Medicare and Medicaid Services, and the Federal Bureau of Investigation.

The cases are entitled United States ex rel. Peter Salvatori and Sara C. Iveson v. Robert Wood Johnson University Hospital at Hamilton, Case No.: 08-1265 (JAG) (D.N.J.), and United States ex rel. James Monahan v. Robert Wood Johnson University Hospital at Hamilton, Case No. 02-5702 (JAG) (D.N.J.).

This settlement is part of the government's emphasis on combating health care fraud. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover approximately $2.3 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department's total recoveries in False Claims Act cases since January 2009 have topped $3 billion. Since 2006, the United States has recovered more than $1.1 billion from hospitals that it alleged engaged in outlier fraud.

SOURCE U.S. Department of Justice