Appalachian Regional Healthcare, Inc. (“ARH”), a hospital system based in eastern Kentucky, and one of its cardiologists have agreed to collectively pay the United States $3,033,861.92 to settle civil allegations that they submitted, or caused the submission of, improper claims to Medicare and Kentucky Medicaid for non-covered services. The case arises from diagnostic cardiac catheterizations and associated services performed or ordered by Padubidri Chandrashekar, MD, a cardiologist who had admission privileges at ARH. Diagnostic catheterizations are minimally-invasive imaging procedures that can be used to evaluate heart problems. During the procedure, a thin, hollow tube is introduced into a patient’s blood vessel and then advanced to the heart, so that pressure and blood flow can be measured in the heart’s chambers or dye can be injected to allow x-ray visualization of the heart. Medicare and Kentucky Medicaid reimburse medical providers for services and procedures, such as diagnostic catheterizations, only when medically reasonable and necessary. Medicare and Kentucky Medicaid require that the patient’s records adequately document the medical need for the service provided.
The United States alleged that Dr. Chandrashekar caused ARH to bill Medicare and Kentucky Medicaid for diagnostic catheterizations performed at ARH Hazard that did not have sufficient documentation to support the medical necessity of the procedures. The United States also alleged improper billing in connection with services performed prior to the unnecessary catheterizations. Specifically, the United States contended that Dr. Chandrashekar and his practice, Mountain Heart Center, billed for medically unnecessary appointments in the days preceding patients’ diagnostic catheterizations and admitted patients to ARH Whitesburg in advance of their diagnostic catheterizations. The United States contended that ARH then submitted false claims to Medicare and Medicaid for those admissions, because the admissions did not meet Medicare and Medicaid’s requirements for severity of illness or intensity of services. Finally, the United States alleged that Dr. Chandrashekar caused the submission of improper claims for ambulance transfers for patients unnecessarily admitted to ARH Whitesburg who needed transport to their catheterizations at ARH Hazard.
