Nathan A. Adams IV is a Partner in Holland & Knight's New York office.
In United States ex rel. Wollman v. General Hosp. Corp., No. 1:15-cv-11890-ADB, 2019 WL 2501669 (D. Mass. June 17, 2019), the district court ruled that a relator's claims that a hospital wrongly billed the government for time patients spent in surgery without a teaching physician immediately available in the room were not "minor or insubstantial" billing rules, and, although "they may not be among the most central to the Medicare and Medicaid programs overall, they are sufficiently central to the payment scheme for concurrent and overlapping surgeries to have received congressional attention and expressions of concern over noncompliance." Specifically, the relator, a former treating anesthesiologist at the defendant hospital, alleged that teaching surgeons routinely left patients who were undergoing surgery alone with residents and fellows in order to conduct concurrently scheduled surgeries, and that they did so without identifying another qualified teaching physician who would be immediately available in the event of an emergency and without keeping proper records or obtaining the patients' informed consent. The relator also claimed that the practice resulted in patients being under anesthesia for extended, medically unnecessary periods. To receive Medicare payments for services performed by a teaching physician, the services must either be "personally furnished by a physician who is not a resident," or "furnished by a resident in the presence of a teaching physician," except in certain specified situations. 42 C.F.R. §§415.170, 415.172. When a teaching physician is not present during portions of the procedure that are not critical or key and is participating in another surgical procedure, he or she must arrange for another qualified surgeon to immediately assist the resident should the need arise. When submitting a claim for reimbursement, the hospital certifies compliance with these Medicare rules and regulations for payment.
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