MAY 21, 2024. Cape Cod Hospital (CCH), based in Massachusetts, has agreed to pay $24.3 million to resolve allegations that it violated the False Claims Act by knowingly submitting claims that did not comply with Medicare requirements. The claims, brought by a whistleblower in a qui tam lawsuit, are centered around a specific cardiac procedure introduced to CCH in 2015. The whistleblower will receive a $4.6 million award or almost 19% of the settlement.

From November 2015 through December 2022, CCH allegedly violated Medicare requirements regarding transcatheter aortic valve replacement (TAVR), submitting around 800 claims that did not meet the requirements. TAVR is intended for patients suffering from aortic stenosis, a heart condition that occurs when the aortic valve narrows, restricting blood flow at proper rates from the heart to the rest of the body. If not treated, the condition can lead to heart failure. The procedure involves replacing the valve with a functioning, artificial one.

Medicare requires hospitals to have several specialists and doctors independently examine the patient to determine their eligibility for TAVR and share such determinations along with rationale for the decision to the entire medical team. According to the allegations, CCH knowingly submitted claims for TAVR to Medicare that did not comply with such requirements. Frequently, too few physicians examined patients’ eligibility for TAVR. Additionally, the examining physicians did not document or share their findings with the TAVR medical team.

The Acting United States Attorney for the District of Massachusetts stated:

Medicare permitted coverage for this newly developed cardiac procedure only under certain conditions, to ensure patient safety. Cape Cod Hospital ignored those rules and received millions of dollars from Medicare to which it was not entitled. This conduct persisted for years despite internal warnings … This investigation and settlement ensure that patient safety is prioritized over a hospital’s bottom line.

CCH has also agreed to a five-year Corporate Integrity Agreement with the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), which requires an independent review of its paid Medicare claims. The hospital received credit from the DOJ for its cooperation in the case.

The suit was brought by Dr. Richard B. Zelman, an interventional cardiologist employed by CCH, under the qui tam provisions of the False Claims Act, which allow for private citizens to bring a case on behalf of the United States. Whistleblowers who expose fraud against the government may receive 15-25% share of the settlement amount. In this case, Dr. Zelman will receive $4.36 million.