Two long-time emergency room doctors have blown the whistle on what they say is fraudulent overcharging by HCA Healthcare, which owns Mission Health, and its medical staffing company, TeamHealth, according to a recently unsealed lawsuit filed last year.
HCA Healthcare and TeamHealth have intentionally run up patient costs with medically unnecessary trauma alerts and added tests, such as CT scans, extra blood samples and X-rays, according to the complaint from Allen Lalor and Scott Ramming. Both have served for more than two decades as emergency physicians in Mission Hospital in Asheville and its regional affiliates.
HCA Healthcare and TeamHealth have systematically defrauded the state and federal Medicare and Medicaid programs under the False Claims Act, according to the lawsuit.
The complaint notes that both companies, which are for-profit corporations, have been sued previously for over billing under the False Claims Act.
The lawsuit was one of two filed last year out of Western North Carolina alleging TeamHealth uses deceptive methods to charge patients for more care than they receive.
Another complaint filed in U.S. district court in Tennessee in November on behalf of Buncombe County alleged TeamHealth was coding ER patients for more severe medical situations than they actually experienced. The same attorneys representing the Mission emergency doctors also are representing Buncombe County, which is suing on behalf of nearly 3,700 employees and the health plan it established for them.
That case is ongoing in Knoxville, where TeamHealth is headquartered.
The emergency doctors’ lawsuit was filed in June 2022 and was sealed until April 6 when the US government declined to intervene. With that decision by the US District Court for the Western District of North Carolina, the case had 90 days to proceed. If no action is taken by July 5, the case will be dismissed.
“We believe that these allegations are meritless and are pleased that the federal government chose not to participate in this case,” Mission Health spokeswoman Nancy Lindell said.
TeamHealth spokesperson Josh Hopson declined to comment.
“We can only comment on information that is available on the public record,” DOJ spokeswoman Lia Bantavani said, “And there is nothing publicly available I can share on this matter beyond what is contained in the document you already have.”
Attorneys for Wallace & Graham, the Salisbury-based law firm representing the doctors, would not comment.
Trauma alerts are a lucrative source of profits for HCA, which can charge thousands of more dollars if one is activated. Doing so upon a patient’s arrival in the emergency room launches a variety of medical specialists’ care. The patient then incurs a trauma fee on top of any charges for treatment, procedures and medications.
Mission is the only certified Level II Trauma Center in Western North Carolina. It accepts all trauma patients in the region, making its emergency room one of the nation’s busiest.
A 2014 investigation by the Tampa Bay Times using 66,000 Florida trauma patients’ billing records found that HCA’s overcharging for trauma codes was on average $40,000 more than other state trauma centers for injured patients. When it came to severity of injury, HCA patients were, on average, the same as the state as a whole, according to the Tampa Bay Times report.
Doctors allege non-physicians activate codes
In the North Carolina whistleblower complaint, the doctors said unnecessary trauma codes were typically activated by a non-physician, often a physician’s assistant, who was given little time to make an actual assessment.
Ramming described a meeting in the office of Chad Patrick, the CEO of Mission Hospital, in which HCA Mission announced that it would lower the threshold for activating trauma codes and alerts, according to the lawsuit.
Lalor, who provided extensive internal memos from TeamHealth, said that a trauma alert would be activated if a geriatric patient on blood thinner (including aspirin) fell from any height with any sign of head trauma. Lalor considered this instruction too broad.
Trauma alerts were mandated for anyone older than 65 with a systolic blood pressure of 110 or less. Again, the doctors considered this to be far too crude a measure and overly inclusive, according to the complaint.
In one instance, Ramming described an incident in which an 82-year-old patient, who had other medical problems, arrived by ambulance with a scrape on his head, and a trauma alert was needlessly activated.
“This is one of innumerable instances where geriatric patients are given unnecessary trauma designations for absurdly minor injuries, when a more rational approach would be to medically evaluate the patient and determine what the problem is, rather than mobilizing unnecessary resources,” Ramming said. “As is so often the case, in instances like this, this patient was actually medically sick and had no traumatic injuries.”
He noted that this patient’s visit to the emergency room occurred on a day when over 40 other patients were waiting to be seen, some for more than five hours. Ramming said these kinds of trauma alerts force other much more ill patients to wait.
In another unwarranted trauma alert, a 79-year-old patient arrived after a car accident, but had no injuries, according to the complaint.
Allegations of a surge in trauma activations
After April 15, 2020, when TeamHealth started delivering contracted services to Mission Hospital’s Emergency Department, the number of trauma activations surged, according to the lawsuit. The doctors said the higher and more lucrative volume of alerts by TeamHealth and HCA Health occurred despite no change in the acuity of the patient population.
On one busy ER shift in May 2022, Ramming witnessed many medically ill patients getting trauma designations, yet many ending up going home, according to the complaint. When he commented on this to the physician’s assistant who was on duty, the response was “trauma overcalls aren’t a problem for corporate medicine,” according to the complaint.
A similar alert that HCA Healthcare and TeamHealth frequently activate is a “sepsis alert,” which triggers many tests and costly treatments. Sepsis is the body’s extreme response to an infection and is life threatening.
Ramming described a case of an 85-year-old woman who came to Mission’s Highlands hospital emergency room with cat scratches and was given a sepsis alert. He canceled the tests, which were “not needed for cat scratches, needless to say,” he said.
Mid-level practitioners in the emergency department were incentivized to order numerous unneeded or redundant lab tests, including blood samples, urinalysis, laboratory analyses, metabolic panels, CT scans and X-rays, according to the lawsuit.
Multiple examples of redundant testing and scanning were in the doctors’ medical records as part of the complaint. In one instance when a patient arrived in Mission’s emergency room a few hours after undergoing urine tests at an urgent care facility, the hospital ordered repeat tests and the full array of sepsis tests. “There was no need for these repeat tests, and the patient was not ill enough to get the sepsis bundle,” Ramming said.
He also noted that it was common to over-code patients as sepsis cases because it not only pads the bill for extra testing, but also pools non-septic patients with truly sick ones, lowering the overall mortality rate.
A blatant example of “how extreme HCA Mission has become in over-ordering tests,” according to the complaint, occurred when a patient who had the jitters after consuming energy drinks was given Lab tests, oxygen, a chest X-ray and an IV.
“Even a layperson with common sense could explain this patient’s jitteriness,” Ramming said.
Unnecessary testing is ordered by physician assistants who perform triage for the emergency room, where they “have only a very limited ability to interview the patient, really examine the patient or spend time with the patient to determine what is really wrong with the patient,” Ramming said.
The changes in practices by HCA and TeamHealth are presumably occurring at other large HCA and/or TeamHealth emergency departments, the complaint said. HCA, based in Nashville, is the largest hospital operating company in the US, with more than 180 hospitals.
The doctors also describe a performance metric system put in place by HCA Health that pressures doctors and other non-physician practitioners to see patients more quickly. A chief metric “is generally speed of service,” according to the complaint.
“A conveyor-belt, fast food approach”
The changes imposed by HCA and TeamHealth “have forced physicians, mid-levels and nurses alike into adopting a conveyor-belt, fast-food approach to emergency medicine, which is counterproductive both for their experience as employees, and for the experience of patients.”
The system is also used to rank doctors against one another and set compensation bonuses, according to the lawsuit.
Ramming has served as the assistant director of the Asheville Emergency Department. But after HCA and TeamHealth took over and he provided management with an honest report about the problems and poor practices there, he was demoted, according to the complaint. He continues to work at Mission Health. Lalor has retired. Neither doctor would speak with Asheville Watchdog.
Other doctors have called Mission’s environment toxic for medical professionals, and many have left since HCA took over, The Watchdog has previously reported.
The North Carolina complaint is seeking three times the fraudulent charges to Medicare and Medicaid, civil fines and attorney fees.
Wallace & Graham also are attorneys for two antitrust class-action suits filed against Mission and HCA. One was brought last year by two counties and cities including Buncombe and Madison counties, and the cities of Asheville and Brevard, all of which have self-funded insurance plans. The other was brought by individual Asheville-area plaintiffs, the first WNC class-action lawsuit since the 2019 takeover. That case is still being litigated in North Carolina Business Court in Raleigh.
Attorney General Josh Stein is not getting involved with this case, according to spokeswoman Nazneen Ahmed. “Our office has declined to intervene at this time, but we are following it closely as we continue our work to ensure fair competition in health care in western North Carolina,” Ahmed said.
In 2003, HCA was involved in the largest health care fraud case in U.S. history at the time, which resulted in $631 million in civil penalties and damages from false claims submitted to Medicare and other federal health programs.
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and surrounding communities. Barbara Durr is a former correspondent for The Financial Times of London. Contact her at bdurr@avlwatchdog.org. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org.
what !!!! HCA is ripping us off !!! who would have guessed. oh wait, I would have guessed that.
You should also be checking physicians with private offices. Since Covid they are uping the # of times they “need” to check you in a year even if you are not displaying any symptoms or problems and ordering tests (within their office) that again you do not show symptoms of, such as eye tests for glaucoma every 3 month and your sight & pressure is fine and no family history. So, maybe a lot of unnecessary medical things have/are being done to catch up on the $ lost during the Covid isolation.
My Doctor sent me to Mission ER when I did not respond to treatment for a UTI. The Doctor called ahead suspecting Sepsis. (I have had it before) I sat for 16-1/2 hours in the ER before any treatment was started. BP went up to 264/110. I had no monitors no BP cuff, no oxygen level, nothing. My daughter finally called the ER and I finally got some quick attention and spent the next three weeks recovering from their failed system. So maybe they were not alerting to sepsis anymore. They went from one extreme to another!
Having investigated Medicare fraud cases for many years, readers can be sure that what these doctors are alleging is just the tip of the iceberg. If HCA is committing fraud in one area of their patient services, it is certainly doing it in others. But never fear, Josh Stein is on the job, keeping HCA “under observation”. By neglecting to get involved in this matter, Stein is repeating his acquiescence to HCA and everything they do in the State of North Carolina. Remember folks, that HCA slickly took over Mission, which was a wonderful non-profit asset serving NC residents. Other bidders were discouraged while Mission’s CEO negotiated a lucrative side contract with HCA for non-specified “consulting”. Stein was “closely monitoring” that business also. How is that working out? What a tangled mess it is when corporate influence and money impacts a government that supposedly “represents” its citizens.
Why is anyone surprised?
And I really do wish much happiness to Ron Paulus and the last board of trustees of the non-profit Mission Hospital, who are all so deserving of our thanks for their selfless acts (all in my opinion).
Certainly you are being sarcastic. Do you have any clue how much Ron made a month? Selfless it is not.
Please folks
We do not want Duck Dive Stein as AG. But God help us if he becomes Governor.
Where the hell was Josh Stein when he was supposed to be overseeing this sale and now protecting NC consumers.The worst attorney general we have ever had. Please remember this when he runs for governor next year.
before you give up on Stein, please inform yourself about the policies of his likely opponent. The lesser of two evils is in play this time for the Governors race..
The huge conglomerate of HCA is frightening. We are all at the mercy of our local hospital and we need to be able to trust that it will provide solid, professional care when we need it. I hope the ER doctors’ lawsuit can make a difference but I also know the detail, time and money to attack such a corporation is daunting. At least the situation is coming to light. Thank you for the news you provide.
When I was a patient there it seemed clear to me they were soaking up as much Medicare money as possible. Useless doctor visits and some useless tests too. I’d love to see them go back to being non-profit.
Hopefully, a future story will provide the dollar figures and who gets what. How much does HCA reap? What does insurance think about it — or do they even care? I hide my full name, because it would surprise me for HCA to red flag names should we ever have to have their services.
The moral to this story is that if you are 65 or on medicare and seek services at Mission you will be a pin cushion, a lab rat, and a cash cow for TeamHealth and HCA. These are unnecessary procedures being implemented to make money, what if a necessary procedure is not ordered because they would lose money? It can cut both ways. This is dangerous life risking territory we are in. If you get out unscathed, consider yourself lucky. Your care is not dictated by your condition, its metrics, as in what will make the most money for them. How could that possibly go wrong? It is shameful that NC has not stepped into this case and it speaks volumes. It is vulnerable seniors at most risk of harm and our federal and state governments can’t be bothered. Is Josh Stein just lazy or is there more to it? He got all worked up about the google lawsuit and vaping but stuck us with this death trap of a hospital and walked away. But rest assured, he’s “monitoring” the situation. Whatever became of the cancer pharmacy closing and the cancer doctors leaving? You can’t get much lower than callously making cancer patients lives more difficult. You also can’t run for governor of pro corporate NC and call out the biggest healthcare corporation in the US for greed and harm, especially when you’re the one who rubber stamped the shady deal. There seems to be a conflict of interest there. Stein should not be the gatekeeper for NC joining these lawsuits. He has an incentive for them just to go away. Medicare doesn’t question billing like private insurance companies do because they don’t have the manpower to do so and its taxpayer money, so who cares. They also don’t investigate hospitals properly for the same reason. There is no real oversight for what they are getting away with and they know it, they’ve been doing it for decades nationally. Only the AVL Watchdog is keeping an eye out for us. Keep barking, keep digging.
If speed of service is a metric, the family that waited 24+ hours in the ER just to be seen might beg to differ. I spoke with them. Ditto for a friend who has sat around in the ER holding room waiting for treatment for 8 hours and eventually discharging themselves when no service was provided.
Excellent article! However…
Why is a female interviewee a “spokeswoman”, but a male interviewee is a “spokesperson”?
Great question. With a few exceptions, Asheville Watchdog uses the Associated Press Stylebook 56th Edition, which instructs us: “In general, use terms such as chair or chairperson, councilperson or council member, and spokesperson unless the -man or -woman terms are specified by an organization.” If a spokesperson tells us he/she prefers spokesman/spokeswoman, we try to honor that.
Well this dynamic happens about 2% of the time………
I to was overcharged $10,000. At the er done a test on my liver, went I knew what was wrong I came in with Covid needed fluids never got them they would come and say start in a minute spent me home so sick four day later my husband got covid never go come home for good
I avoid Mission Hospital. I laid in ER under “observation” for six hours while a massive blood clot was traveling up my femoral vein to the main abdominal vein. The pain was like a rope with a knot in it from mu left hip to the arch of my left foot. I was se t there by my physician to get a screen inserted but nope. Observation meant that I was given no water, and if course nothing for the immense pain becaise u might be a pill addict… and the young ER doctor said to me, ” You are probably going to deal with the pain fir the rest of your life.” I said to him, Someday you might be on this slab like I am. How would you react if a young doctor said that to you? ” His female assitan6 said that I was being rude. I took my iv out and walked out of there. Rude indeed.
I had to undergo emergency surgery at Mission a few years ago. About an hour before the procedure (while I was receiving morphine and alone) a finance person from HCA came into my hospital room and tried to convince me to sign a form stating I would receive a “20%” discount on my out of pocket costs if I paid my bill before they sent it to my insurance. The “20%” discount was hand-written (presumably in error) as “0.20%”, but never mind that! Even in my impaired state I was able to say “no thanks – please send the bills to my insurer”. I wonder how many vulnerable members of our community fall for that. If it isn’t already, what they attempted in my hospital room that day should be illegal. It’s disgusting that we’re forced to seek life-saving treatment at a for-profit hospital.
I had the absolute worst experience at Mission ER. I was brought in by EMS after breaking my forearm in half, EMS gave me pain medication and twilight to be able to splint my arm and make the ride to the ER easier and by the time I arrived everything was wearing off, the ER removed the temporary splint to x-ray my arm but it took a long time before the portable machine and x-ray tech came to the room and mean while my arm was practically hanging goosenecked. I was in extreme pain, the doctor refused to give me any pain medication, even when x-ray arrived and had to manipulate my arm, they still refused pain medication, both the bones in my arm were broken and when they set and casted it they still refused pain meds, I passed out from pain several times, the times I was awake and screaming in pain the nurses just glared at me and when I called one out on it she just came over and slammed the door. All in all I was in the ER for 5 hours in torturous pain and about 30 min to an hour before discharge they gave me an oral pain medication. After all that HCA ended up charging me for pain medication that was never administered, charged for casting my arm twice and for double x-rays, my insurance company rightfully refused payment stating those reasons, so HCA sent me the bill for the unpaid charges that I am currently disputing.
Mission has gone as far downhill as possible. HCA hadms a monopoly on Healthcare in WNC. I’ve been leaving all my doctors for doctors in Tennessee and I feel much more cared for and safe. I recently ended up in dire straits physically and needed emergency care. Instead of that death trap, I went to Franklin Woods Hospital in Johnson City. I was treated immediately, admitted and in a private room within a few hours. The quality of care I received was amazing and the araff kind, patient and thorough. I’ll never go back to anyone affiliated with these HCA/Mission monsters.
Why is the Attorney General not getting involved?
because he is running for governor and would prefer not to talk about the terrible sale of our hospital to a for profit corporate entity that he helped approve, chris.
We live in FL, and took my son in to an HCA ER here after he was bitten by a dog. The bite was not severe but we wanted to get him checked out, and since it was 10:30 at night, we chose that ER, less than 10 minutes from our house.
We were in the facility for less than an hour. We saw a dr for less than 5 minutes. He did not need stitches, was cleaned with saline and gauze by the nurse, and given one oral dose of antibiotics. He was prescribed more antibiotics and topical antibiotic cream as well, which we filled the next day at a separate pharmacy. Imagine our surprise a few weeks later when we received a call from HCA offering us a “charity case” discount! We have insurance, so why was this needed? She said it was because the BALANCE left after our insurance deductible was taken out was over $1600. Our deductible was $1600. So, our insurance received a bill for over $3000 for this non-emergency situation from the hospital (in addition to the $900 bill for the doctor who basically did nothing). His case was coded as a Level 3 visit. When we Googled this (because there was nothing itemized for us beyond the medicines) we discovered that Level 3 is charged when ANY prescription medicine is given or prescribed. Since my 8 year old son was given antibiotics, this “technically” qualified. Level 3 is also charged for people who ride to the hospital in an ambulance, need splints or shunts, need x-rays, or receive opioid pain medication.
Being able to charge this amount for a situation like ours vs a TRUE Level 3 emergency is totally unethical and completely fraudulent. We were given the run around when we wanted copies of his records from that visit. We went back and forth with administration (very hard to get in touch with) asking for audits and appeals and asking them to recode our visit but we were denied. We had an independent audit done as well. We finally ended up paying the huge balance when they sent our account to collections 10 months later because we didn’t even know what else to do.
This article really resonates with the experience we went through, and knowing it’s happening all over the country with this company is just infuriating.
Schemes like this only work when doctors are complicit.
These 2 whistleblowers had the courage to stand up and try to protect patients from financial and medical harm but the gov’t won’t step in and do the same. How many hundreds of doctors at this hospital are looking the other way while patients lives are sacrificed for money? It is not only the ER. Yes, doctors have big student loans to repay and families to feed, careers to protect, etc. But they’re doing it at the expense of the lives of sick and vulnerable people. So they can get their metric bonus check? That oath about doing no harm doesn’t mean much. HCA trained residents have trouble finding jobs in other hospital systems as they are considered to be poorly trained and tainted by HCA’s corrupt and immoral practices. Tell me again why Josh Stein’s hands were tied, but this deal could not go through without his approval? That never made much sense.
“The US government declined to intervene”.
The story of a lot of doctors’ lives. The Feds sit on the sidelines and watch us BLEED OUT fighting their battles.
We came here looking to move permanently but w will not be, due to the lack of decent health care. I don’t know whose bright idea it was to allow HCA, a for-profit company, to buy the nonprofit Mission Hospital. My guess is that it goes to the NC Legislature bc it sounds like a typical Republican move. Now everyone is complaining that quality is suffering, there’s only one oncologist bc 14 left in 2019 and no others will contract at the rates HCA is paying, and HCA is defendant in an antitrust lawsuit be if they can’t block Advent and Novant from coming here, they’ll go bankrupt bc anything is better than HCA.
It is no surprise that HCA puts profits above patient outcomes, decent doctors, or that it’s pumping up it’s billings. The whole point of a for-profit corporation is to make money first and foremost. Unless you get competition here that makes HCA either provide exceptional health care or go out of business- which is exactly what capitalism is supposed to do – you’ll see people leaving for places they can get their chemo or having their baby delivered. It’s funny how they want to be capitalist while also being protected from the requirement that they actually compete.