UTSW AND PARKLAND RESOLVE ALLEGATIONS OF IMPROPER
PHYSICIAN SUPERVISION OF SURGICAL RESIDENTS
DALLAS — The University of Texas Southwestern Medical Center at Dallas; the University of Texas Southwestern Medical Center at Dallas Medical Service, Research, and Development Plan; the University of Texas Southwestern Health Systems a/k/a UT Southwestern Health Systems (collectively “UTSW”) agreed to pay the U.S. and Texas $1.4 million to resolve allegations that it, along with the Dallas County Hospital District d/b/a Parkland Health and Hospital System (Parkland), violated the civil False Claims Act and Texas Medicaid Fraud Prevention Act, announced U.S. Attorney James T. Jacks of the Northern District of Texas. The U.S. and Texas contend defendants caused “upcoded” claims to be submitted to Medicare and Medicaid for teaching physician-related items and services between 2004 and 2007. Defendants fully cooperated with the investigation, and by settling, did not admit any wrong-doing or liability.
Teaching physicians may submit claims to Medicare and Texas Medicaid for the supervision of residents if they meet certain criteria. Claims generally are reimbursable if the teaching physician is present for the key or critical portion of the service. Supervision of a resident is noted by coding a claim with the modifier GC. Surgeons typically are paid a global fee which represents payment for pre-, intra-, and post-operative management of a patient’s care. The United States and Texas contend UTSW submitted improper claims primarily due to its teaching physicians’ inadequate supervision of residents during certain key portions of pre-, intra-, and post-operative care of surgeries performed at Parkland Hospital. The United States and Texas allege claims with modifier GC falsely represented to the Medicare and Texas Medicaid programs that UTSW’s teaching physicians properly supervised surgical residents at Parkland, even though in some cases, there was no documentation by the physicians that they were present for the critical portion of the resident’s pre-, intra-, and post-operative surgical care.
The U.S. and Texas initiated the investigation in response to a June 2007 whistleblower suit brought by Larry M. Gentilello, M.D., the former chair of the Burns, Trauma, and Critical Care Division at UTSW Medical Center at Dallas. Under the False Claims Act and Texas Medicaid Fraud Prevention Act, private individuals may bring actions alleging fraud on behalf of the U.S. and Texas and collect a share of any proceeds recovered by the suit. Dr. Gentilello can receive up to 25% of the recovery under the settlement.
U.S. Attorney Jacks praised the efforts of the Office of Inspector General of the U.S. Department of Health and Human Services (OIG). “Medicare should get what it pays for. If you submit a claim for supervising a resident you should actually be present supervising that resident, particularly when that resident is performing surgery,” said Mike Fields, Special Agent in Charge of the Dallas office of the OIG.
The case was handled by Assistant U.S. Attorney Sean McKenna and Assistant Texas Attorney General Paula Juba. The case is captioned United States of America, et al., ex rel. Larry M. Gentilello, M.D. v. The University of Texas Southwestern Health Systems, et al.; No. 3-07-cv-1172-K (N.D. Tex.).