Hospital giant HCA pushes back on questionable hospital admissions charges


Jennifer Smithfield was feeling weak and still struggling to breathe in February after nearly two weeks with covid-19. It was a Sunday and her doctor’s office was closed. His attending physician therefore suggested going to the emergency room to be safe.

Smithfield went to HCA Healthcare’s flagship hospital near its headquarters in Nashville, Tennessee, and thought she would be checked and sent home. But that’s not what happened.

“Even though I didn’t feel well, I didn’t think it was serious enough to be hospitalized, especially not for several days,” Smithfield said.

Within three days, Smithfield racked up $40,000 in charges for her hospital stay and was billed $6,000 under her health insurance policy. “I could have walked out,” Smithfield said. “I wish I had come out.”

While she was in the hospital, she said, the doctor who referred her to the ER repeatedly texted her, asking why she was admitted.

For more than a decade, major health systems have come under scrutiny for admitting patients to expensive hospital stays when cheaper treatments or short periods of observation in the emergency room would have been appropriate. .

Commercial insurers pay generously for hospital care, with room rates often reaching several thousand dollars a day — and that doesn’t include the costs that inevitably follow for blood tests, consultations, and other examinations that typically occur. Hospitals, like hotels, maximize revenue by keeping their beds full.

Critics allege that HCA sought to keep occupancy rates high by creating incentives for doctors to admit patients to the emergency room — whether those patients needed to be admitted or not. The charge is particularly surprising because nationwide admission rates have generally declined as more conditions can be treated safely through telemedicine and home monitoring.

Jennifer Smithfield reviews detailed billing statements from her stay at an HCA Healthcare hospital.(Nathan Lambrecht for KHN)

U.S. Representative Bill Pascrell (DN.J.) and the Service Employees International Union lobbied the Department of Health and Human Services to investigate the allegations against HCA as potential Medicare fraud. A spokesman for the Centers for Medicare & Medicaid Services, Bruce Alexander, said the agency is reviewing a September letter from Pascrell that details claims that HCA forced doctors to meet unofficial quotas, or targets, for the number of patients admitted to the hospital. And a previously sealed whistleblower case sheds new light on those internal policies.

“Inappropriate hospital admissions can have cascading effects on patients and workers,” Pascrell, chair of the House Ways and Means Oversight Subcommittee, wrote to HHS Secretary Xavier Becerra. “Unnecessary admissions expose patients to unnecessary treatment. This creates an additional potential risk of complications and the possibility of new infections for patients.

HCA spokesman Harlow Sumerford denied the charges. “We categorically reject any allegations that physicians admit patients to our hospitals based on anything other than their independent medical judgment and the individual conditions and medical needs of their patients,” he told KHN in a statement.

Pascrell’s concerns are largely based on a 58-page SEIU investigative report released in February. The national union has been challenging health systems on admissions for more than a decade as it tries to organize in more for-profit hospitals and defends its members who work on the front lines. The SEIU estimates that HCA overcharged the Medicare program by at least $1.8 billion over about a decade due to excessive admissions, according to the report.

The claims against HCA are similar to those the SEIU made that led to a $98 million settlement with Community Health Systems in 2014 and a $262 million settlement in 2018 with Health Management Associations. health. The government alleged that hospitals knowingly charged for inpatient services when lower-paying outpatient or observation services were warranted.

The government is in the best position to prove such claims, said Jacob Tubbs, a Birmingham, Alabama-based lawyer whose law firm, Price Armstrong, has represented plaintiffs in similar cases against hospitals. But he noted that it was difficult to prove that doctors deliberately and systematically deviated from the current standard of care. It is particularly difficult to show that a patient has been overtreated.

Lawyers still have “a healthy dose of skepticism” about the possibility of winning these cases, he said. “We know what we’re going to have to prove ultimately is that the medical care was objectively unnecessary.”

In a 141-page court filing from 2018, Dr. Camilo Ruiz, a whistleblower at a 400-bed HCA hospital in suburban Miami, accused the health care system of threatening his job if he didn’t admit more patients. , instead of sending them home. emergencies. HCA supervisors harassed him with warnings to begin meeting established goals, he said in court documents.

Ruiz’s attorneys used publicly available Medicare data to show that HCA hospitals around the country routinely admit patients for low-grade illnesses such as abdominal pain, lower respiratory issues, dizziness and nausea, while non-HCA hospitals were sending home patients with the same conditions.

At 41 HCA hospitals with the highest admission rates — located in Florida, Texas, Nevada, Virginia, and California — advocates found that from 2013 to 2016, 84% of Medicare patients were admitted for eight common diagnoses, compared to 55% at non-HCA hospitals.

The Ruiz case was unsealed in 2020 when the federal government refused to take over the investigation. The Justice Department — which has intervened in similar cases that resulted in settlements — did not explain in court records why it forwarded the Ruiz case and declined to comment on KHN.

Ken Nolan is an attorney at Nolan Auerbach & White, a firm based in Fort Lauderdale, Florida, and has successfully represented whistleblowers alleging fraudulent hospital admissions. Nolan said the government sometimes refuses cases for reasons other than lack of evidence.

A photo shows Jennifer Smithfield highlighting sections of her medical bills.
Jennifer Smithfield highlights the charges she plans to dispute in an itemized billing list for her stay at an HCA Healthcare hospital.(Nathan Lambrecht for KHN)

The SEIU continues to push the government to investigate its broader allegations against the HCA. The union incorporated data from the Ruiz lawsuit into the report it reviewed with government agencies, including the Securities and Exchange Commission.

In addition to asking HHS to investigate, Pascrell sent a letter directly to HCA CEO Sam Hazen asking for an explanation for the high number of admissions.

As the nation’s largest hospital company, HCA sets the tone for America’s healthcare system. Its profits approached $7 billion in 2021 even as other healthcare systems struggled against the tailwind of the pandemic.

For Smithfield, his costly hospitalization didn’t just threaten his wallet. It has also shattered her trust in a system in which she has long received care, including treatment for leukemia. She disputes her bill.

Now, when seeking medical attention, she wonders if “her best interests are considered over some other motive the hospital administration may have.”

This article is from a partnership that includes Nashville Public Radio and KHN.

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