U.S. ex rel. Ortiz v. Mount Sinai Hosp. — Nov. 2015 (Summary)

FALSE CLAIMS ACT

U.S. ex rel. Ortiz v. Mount Sinai Hosp.
No. 13 Civ. 4735 (RMB) (S.D. N.Y. Nov. 9, 2015)

The United States District Court for the Southern District of New York denied a hospital’s motion to dismiss claims made under the False Claims Act (“FCA”).

The relators who brought forth the claims were employed by the hospital as patient coordinators. They alleged that during their tenure they witnessed on a near-daily basis instances where the radiology billing department billed Medicare and Medicaid fraudulently and improperly for services purportedly provided. Specifically, they alleged that department engaged in doctor swapping, upcoding, phantom billing, multiple billing, combination misbilling, and wrongful retention.

The hospital responded by arguing that the relators improperly obtained confidential patient records as the basis for their complaint; that the medical records integral to the complaint contradict the allegations; and that the allegations failed to plead sufficient facts.

The court reasoned that it was premature to conclude that the records were obtained improperly because there is a strong public policy in favor of protecting those who report fraud against the government. The court also stated that it would be inappropriate to discredit the factual allegations of a complaint merely because they are contradicted, and that the relators adequately pled their claims.