A recent qui tam Medicare lawsuit battle is progressing in favor for the whistleblower who claims a group of doctors and a UPMC-owned hospital allegedly falsified Medicare records.

A Pennsylvania federal judge ruled in favor of the whistleblower party after reviewing the alleged arrangements between the doctors and medical care facility accused of falsifying Medicare reimbursements for referrals.

According to the qui tam Medicare lawsuit, there were two agreements made between the doctors and UPMC hospital that allegedly manipulated Medicare reimbursements for referrals and that there was evidence indicating a beneficial relationship between the two defendant parties.

This is problematic with federal law, as it does not allow any healthcare provider to submit Medicare claims based on referrals from doctors in which there is a “financial relationship.”

U.S. District Judge Joy Flowers Conti found cardiologist Tullio Emanuele had allegedly shown there had been arrangements between doctors of Medicor Associates Inc. and UPMC Hamot, along with a Women’s Heart Health Program, and the chair of the hospital’s Department of Cardiovascular Medicine and Surgery had violated the Stark Act.

Even though Judge Conti concluded that the original six agreements had established a relationship between the parties, the other allegations were not sufficiently proven with the existing documents.

“The Women’s Heart Health directorship and CV Chair position do not satisfy any of the exceptions cited by defendants. [T]hose arrangements were never set forth in a signed writing or collection of writings and do not meet the requirements of the isolated transactions exception,” Judge Conti said.

Overview of Qui Tam Medicare Lawsuit

According to the qui tam Medicare lawsuit, Dr. Emanuele was employed as a Medicor cardiologist from 2001 to 2005 and had filed the whistleblower complaint in 2010.

In his complaint, Dr. Emanuele alleged the relationship between the doctors and hospital violated the False Claims Act. Even though the government had previously decided not to get involved with the complaint in 2011, Dr. Emanuele decided to pursue the allegations himself.

Dr. Emanuele had filed for summary judgment for his qui tam Medicare lawsuit in 2014, arguing that there was “undisputed evidence” that a kickback arrangement existed and it violated the Stark Act. Judge Conti’s ruling focused on the exceptions of the law, which applied to several of the parties named in the alleged kickback arrangement.

When Judge Conti first looked over the initial six “directorship” agreements between the medical care professionals and the hospital, Dr. Emanuele argued that because they were allowed to lapse several times during a 21 month time span they had violated a requirement that mandated that any such agreements had to be “in writing.”

Judge Conti stated that a jury could reasonably find that there was an agenda, there was a set of original agreements, and could conclude they were in writing. However, Judge Conti stated that the same could not be said for the Women’s Heart Health department chair. Through the litigation process, the qui tam Medicare lawsuit will now go to trial.

This Qui Tam Medicare Lawsuit is Tullio Emanuele v. Medicor Associates Inc. et al., Case No. 1:10-cv-00245, in the U.S. District Court for the Western District of Pennsylvania.