FOR RELEASE July 5, 2016
Contact: Elizabeth Nikels 909-235-4305 enikels@primehealthcare.com
Prime Healthcare’s Response to DOJ Complaint: Prime Healthcare supports physicians and patients in the need for adequate inpatient hospital care (Ontario, CA – July 5, 2016) – The United States Department of Justice (USDOJ) has filed its complaint in intervention in the False Claims Act action regarding Medicare inpatient admissions filed by a former employee. The filing was expected following the USDOJ’s notice of intent to file the complaint on May 23, 2016. Prime Healthcare denies the allegations and remains committed to providing quality care that patients need and deserve. Prime Healthcare is confident that it will prevail and be found to have completely complied with all Federal regulations regarding Medicare inpatient admissions. The USDOJ complaint alleges that Medicare patients could have been treated as outpatients under observation status rather than as inpatient admissions. However, physicians determine medical necessity for admission using their independent medical judgement and nationally recognized objective clinical criteria. Predictably, the complaint alleges that Medicare should have only paid for outpatient observation care even though this reimbursement rate is less than the cost of care provided or expected based on the patients’ medical conditions. Prime Healthcare provides award winning quality care to all patients, earning more patient safety awards from Healthgrades than any other health system in the country and being named a Top 15 health system three times by Truven Health Analytics. Prime Healthcare supports the decisions of physicians in the care they determine is needed for their patients. The USDOJ complaint does not dispute the safety or quality of care provided to patients at Prime hospitals, but instead alleges patients should have been admitted to hospitals under the Medicare observation status, rather than as inpatient admissions, even though the hospital care provided to the patients is largely the same. “Hundreds of independent physicians have used their clinical judgment to determine the need for inpatient care in the best interests of their patients. Physicians determine the need for inpatient admission, not hospitals,” said Troy Schell, General Counsel for Prime Healthcare. In California, Prime Healthcare does not employ physicians in its hospitals. “Every admission decision is based on the clinical judgment of physicians and satisfies nationally recognized objective clinical criteria, including those issued by Milliman and InterQual criteria,” continued Schell. “Medicare has no established criteria aside from the determination of medical necessity made by a physician. The allegation that Prime Healthcare altered Milliman guidelines is false. Prime Healthcare has confidence in the medical judgment of the hundreds of independent physicians that admit patients within our hospitals.” “The rules to determine medical necessity for inpatient admission are a challenge faced by all hospitals," said California Hospital Association President/CEO C. Duane Dauner. "The current maze of federal and state laws is complex, inconsistent, and can create traps for those Prime Healthcare | 3300 East Guasti Rd | Ontario, CA. 91761 Primehealthcare.com | Tel: (909) 235-4400