This story was originally published by:
Barbara Durr and Andrew R. Jones, Asheville Watchdog
June 14, 2023
Two long-time emergency room doctors have blown the whistle on what they say is fraudulent overcharging by HCA Healthcare, which owns Mission Health, and its medical staffing company, TeamHealth, according to a recently unsealed lawsuit filed last year.
HCA Healthcare and TeamHealth have intentionally run up patient costs with medically unnecessary trauma alerts and added tests, such as CT scans, extra blood samples and X-rays, according to the complaint from Allen Lalor and Scott Ramming. Both have served for more than two decades as emergency physicians in Mission Hospital in Asheville and its regional affiliates.
HCA Healthcare and TeamHealth have systematically defrauded the state and federal Medicare and Medicaid programs under the False Claims Act, according to the lawsuit.
The complaint notes that both companies, which are for-profit corporations, have been sued previously for over billing under the False Claims Act.
The lawsuit was one of two filed last year out of Western North Carolina alleging TeamHealth uses deceptive methods to charge patients for more care than they receive.
Another complaint filed in U.S. district court in Tennessee in November on behalf of Buncombe County alleged TeamHealth was coding ER patients for more severe medical situations than they actually experienced. The same attorneys representing the Mission emergency doctors also are representing Buncombe County, which is suing on behalf of nearly 3,700 employees and the health plan it established for them.
That case is ongoing in Knoxville, where TeamHealth is headquartered.
The emergency doctors’ lawsuit was filed in June 2022 and was sealed until April 6 when the US government declined to intervene. With that decision by the US District Court for the Western District of North Carolina, the case had 90 days to proceed. If no action is taken by July 5, the case will be dismissed.
“We believe that these allegations are meritless and are pleased that the federal government chose not to participate in this case,” Mission Health spokeswoman Nancy Lindell said.
TeamHealth spokesperson Josh Hopson declined to comment.
“We can only comment on information that is available on the public record,” DOJ spokeswoman Lia Bantavani said, “And there is nothing publicly available I can share on this matter beyond what is contained in the document you already have.”
Attorneys for Wallace & Graham, the Salisbury-based law firm representing the doctors, would not comment.
Trauma alerts are a lucrative source of profits for HCA, which can charge thousands of more dollars if one is activated. Doing so upon a patient’s arrival in the emergency room launches a variety of medical specialists’ care. The patient then incurs a trauma fee on top of any charges for treatment, procedures and medications.
Mission is the only certified Level II Trauma Center in Western North Carolina. It accepts all trauma patients in the region, making its emergency room one of the nation’s busiest.
A 2014 investigation by the Tampa Bay Times using 66,000 Florida trauma patients’ billing records found that HCA’s overcharging for trauma codes was on average $40,000 more than other state trauma centers for injured patients. When it came to severity of injury, HCA patients were, on average, the same as the state as a whole, according to the Tampa Bay Times report.
Doctors allege non-physicians activate codes
In the North Carolina whistleblower complaint, the doctors said unnecessary trauma codes were typically activated by a non-physician, often a physician’s assistant, who was given little time to make an actual assessment.
Ramming described a meeting in the office of Chad Patrick, the CEO of Mission Hospital, in which HCA Mission announced that it would lower the threshold for activating trauma codes and alerts, according to the lawsuit.
Lalor, who provided extensive internal memos from TeamHealth, said that a trauma alert would be activated if a geriatric patient on blood thinner (including aspirin) fell from any height with any sign of head trauma. Lalor considered this instruction too broad.
Trauma alerts were mandated for anyone older than 65 with a systolic blood pressure of 110 or less. Again, the doctors considered this to be far too crude a measure and overly inclusive, according to the complaint.
In one instance, Ramming described an incident in which an 82-year-old patient, who had other medical problems, arrived by ambulance with a scrape on his head, and a trauma alert was needlessly activated.
“This is one of innumerable instances where geriatric patients are given unnecessary trauma designations for absurdly minor injuries, when a more rational approach would be to medically evaluate the patient and determine what the problem is, rather than mobilizing unnecessary resources,” Ramming said. “As is so often the case, in instances like this, this patient was actually medically sick and had no traumatic injuries.”
He noted that this patient’s visit to the emergency room occurred on a day when over 40 other patients were waiting to be seen, some for more than five hours. Ramming said these kinds of trauma alerts force other much more ill patients to wait.
In another unwarranted trauma alert, a 79-year-old patient arrived after a car accident, but had no injuries, according to the complaint.
Allegations of a surge in trauma activations
After April 15, 2020, when TeamHealth started delivering contracted services to Mission Hospital’s Emergency Department, the number of trauma activations surged, according to the lawsuit. The doctors said the higher and more lucrative volume of alerts by TeamHealth and HCA Health occurred despite no change in the acuity of the patient population.
On one busy ER shift in May 2022, Ramming witnessed many medically ill patients getting trauma designations, yet many ending up going home, according to the complaint. When he commented on this to the physician’s assistant who was on duty, the response was “trauma overcalls aren’t a problem for corporate medicine,” according to the complaint.
A similar alert that HCA Healthcare and TeamHealth frequently activate is a “sepsis alert,” which triggers many tests and costly treatments. Sepsis is the body’s extreme response to an infection and is life threatening.
Ramming described a case of an 85-year-old woman who came to Mission’s Highlands hospital emergency room with cat scratches and was given a sepsis alert. He canceled the tests, which were “not needed for cat scratches, needless to say,” he said.
Mid-level practitioners in the emergency department were incentivized to order numerous unneeded or redundant lab tests, including blood samples, urinalysis, laboratory analyses, metabolic panels, CT scans and X-rays, according to the lawsuit.
Multiple examples of redundant testing and scanning were in the doctors’ medical records as part of the complaint. In one instance when a patient arrived in Mission’s emergency room a few hours after undergoing urine tests at an urgent care facility, the hospital ordered repeat tests and the full array of sepsis tests. “There was no need for these repeat tests, and the patient was not ill enough to get the sepsis bundle,” Ramming said.
He also noted that it was common to over-code patients as sepsis cases because it not only pads the bill for extra testing, but also pools non-septic patients with truly sick ones, lowering the overall mortality rate.
A blatant example of “how extreme HCA Mission has become in over-ordering tests,” according to the complaint, occurred when a patient who had the jitters after consuming energy drinks was given Lab tests, oxygen, a chest X-ray and an IV.
“Even a layperson with common sense could explain this patient’s jitteriness,” Ramming said.
Unnecessary testing is ordered by physician assistants who perform triage for the emergency room, where they “have only a very limited ability to interview the patient, really examine the patient or spend time with the patient to determine what is really wrong with the patient,” Ramming said.
The changes in practices by HCA and TeamHealth are presumably occurring at other large HCA and/or TeamHealth emergency departments, the complaint said. HCA, based in Nashville, is the largest hospital operating company in the US, with more than 180 hospitals.
The doctors also describe a performance metric system put in place by HCA Health that pressures doctors and other non-physician practitioners to see patients more quickly. A chief metric “is generally speed of service,” according to the complaint.
“A conveyor-belt, fast food approach”
The changes imposed by HCA and TeamHealth “have forced physicians, mid-levels and nurses alike into adopting a conveyor-belt, fast-food approach to emergency medicine, which is counterproductive both for their experience as employees, and for the experience of patients.”
The system is also used to rank doctors against one another and set compensation bonuses, according to the lawsuit.
Ramming has served as the assistant director of the Asheville Emergency Department. But after HCA and TeamHealth took over and he provided management with an honest report about the problems and poor practices there, he was demoted, according to the complaint. He continues to work at Mission Health. Lalor has retired. Neither doctor would speak with Asheville Watchdog.
Other doctors have called Mission’s environment toxic for medical professionals, and many have left since HCA took over, The Watchdog has previously reported.
The North Carolina complaint is seeking three times the fraudulent charges to Medicare and Medicaid, civil fines and attorney fees.
Wallace & Graham also are attorneys for two antitrust class-action suits filed against Mission and HCA. One was brought last year by two counties and cities including Buncombe and Madison counties, and the cities of Asheville and Brevard, all of which have self-funded insurance plans. The other was brought by individual Asheville-area plaintiffs, the first WNC class-action lawsuit since the 2019 takeover. That case is still being litigated in North Carolina Business Court in Raleigh.
Attorney General Josh Stein is not getting involved with this case, according to spokeswoman Nazneen Ahmed. “Our office has declined to intervene at this time, but we are following it closely as we continue our work to ensure fair competition in health care in western North Carolina,” Ahmed said.
In 2003, HCA was involved in the largest health care fraud case in U.S. history at the time, which resulted in $631 million in civil penalties and damages from false claims submitted to Medicare and other federal health programs.
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and surrounding communities. Barbara Durr is a former correspondent for The Financial Times of London. Contact her at bdurr@avlwatchdog.org. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org.