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MASS. HOSPITAL TO PAY WHISTLEBLOWER $4.4M FOR FLAGGING MEDICARE VIOLATIONS


 * Updated: May. 17, 2024, 4:30 p.m.|
 * Published: May. 17, 2024, 4:07 p.m.

Cape Cod Hospital. Google Streetview screenshot.
 * 
 * 

By
 * Juliet Schulman-Hall | JSchulman-Hall@masslive.com
 * Ryan Mancini | RMancini@masslive.com

Cardiologist Dr. Richard Zelman is expected to receive $4.36 million in a $24.4
million settlement after Cape Cod Hospital was found to have knowingly filed
claims for heart valve procedures that did not comply with Medicare rules.

The payout to Zelman is the largest-ever false claims act recovery from a
Massachusetts hospital, according to Gregg Shapiro, who represents the
whistleblower.



“Dr. Zelman appreciates that the government conducted a thorough investigation
and that the case has been successfully resolved,” Shapiro told MassLive.



Zelman was director of the hospital’s Heart and Vascular Institute from 2018
until he was fired in September 2022, according to The Boston Globe.

The $24.4 million settlement resolves allegations that between November 2015 and
December 2022, the hospital knowingly submitted hundreds of claims to Medicare
for transcatheter aortic valve replacement, or TAVR procedures, that did not
follow Medicare requirements, Joshua Levy, Acting United States Attorney, said
in a statement.

TAVR procedures are for patients who suffer from aortic stenosis, a serious
heart condition that restricts blood flow from the heart to the rest of the
body.

A TAVR procedure involves replacing a patient’s damaged heart valve with an
artificial one. At the time, Medicare rules required that hospitals engage
specified clinical personnel to conduct a separate, independent examination of
prospective patients to evaluate their suitability for TAVR before the
procedure, Levy said.

Zelman alerted quality of care concerns in a 2022 lawsuit. Zelman later claimed
he was wrongfully terminated after bringing up his concerns, according to the
Cape Cod Times. The lawsuit was later dropped, the outlet reported.



Hospitals are required to document the rationale for their clinical judgment
before the procedure and then make that rationale available to the medical team
performing the TAVR procedure.

Sometimes, there were not enough doctors to examine a patient’s suitability for
the procedure, while at other times, doctors did not document and share their
clinical judgment with the medical team who operated TAVR procedures, according
to Levy’s statement.

Those involved included interventional cardiologists and cardiac surgeons in the
hospital as well as those from Brigham & Women’s Hospital but contracted by Cape
Cod Hospital.

“Medicare permitted coverage for this newly developed cardiac procedure only
under certain conditions to ensure patient safety,” Levy’s statement said. “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.”



In a statement to MassLive, Bruce Johnston, Cape Cod Hospital’s board chairman
emphasized his support of chief executive Michael Lauf, touting him as
contributing to the hospital’s “excellent care” and enhancing the hospital’s
“operational and financial position.”

“Though it is unfortunate to be in this situation, the Board of Trustees remains
confident in and supportive of the organization’s leadership,” Johnston said.

“Under Lauf’s leadership, Cape Cod Hospital has grown both in reputation and in
size and now eagerly anticipates the opening of a new patient care pavilion,
which will house a state-of-the-art cancer center, consolidate the Hospital’s
many cardiology programs, and add 32 more medical/surgical beds to address
increasing demand,” he later added.

 * Read more: Cape Cod Hospital to pay $24.3M for breach of Medicare rules

Along with the settlement, Cape Cod Hospital has begun a five-year Corporate
Integrity Agreement with the U.S. Department of Health and Human Services,
Office of the Inspector General to give an annual review of its paid Medicare
claims by an independent review organization, Levy’s office said.



Cape Cod Hospital also received credit under the Department’s guidelines for
taking disclosure, cooperation and remediation into account in False Claims Act
cases, according to Levy’s office. The hospital voluntarily produced materials,
identified the relevant medical records, admitted to failing to adhere to the
applicable Medicare requirements and implemented the appropriate remedial
measures, among other actions.

These claims were resolved under the provisions of the False Claims Act, where a
whistleblower can file an action on behalf of the United States and receive a
portion of any recovery, Levy’s office said. The whistleblower will receive
about $4.36 million as part of this resolution.



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