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WellStar Health Systems Agrees to Pay $2.7 Million To Settle Investigation Into Medicaid Billing

PRESS ADVISORY

WellStar Health Systems Agrees to Pay $2.7 Million To Settle Investigation Into Medicaid Billing

August 30, 2010

Attorney General Thurbert E. Baker announced today that the State of Georgia has reached a $2.738 million civil settlement with WellStar Health Systems, relating to Medicaid billing for inpatient and outpatient services provided at five area WellStar hospitals: Cobb, WellStar Kennestone, WellStar Windy Hill, Douglas and Paulding.

This settlement follows a six-month investigation by the Georgia Medicaid Fraud Control Unit (MFCU) and the Department of Community Health (DCH), with assistance from an outside auditing firm under contract with DCH.  The focus of the investigation was WellStar’s billing for “cross-over” claims, which are claims made for patients who are enrolled in both Medicare and Medicaid.  Medicare acts as the primary coverage, with Medicaid functioning as the secondary insurance, and Medicaid has a cap on the amount of reimbursement that a hospital can receive.  The investigation found that WellStar filed claims which did not reflect the full amount of Medicare prior payments, allowing WellStar to receive excessive Medicaid reimbursements.

Under the terms of the agreement, WellStar and its Hospitals denied any wrongdoing, but agreed to pay the Georgia Department of Community Health a lump sum of $2,728,318 to settle all possible claims related to the billing errors.  WellStar also agreed to pay the state $10,000 to defray the costs of its investigation.   WellStar cooperated fully with the State’s investigation, and implemented corrective actions to ensure that similar billing problems do not reoccur.

In announcing the settlement, Attorney General Baker emphasized that “Georgia’s Medicaid Fraud Control Unit will continue to vigorously investigate all instances of overbilling as well as fraudulent billing in the Medicaid system.   Active enforcement and oversight are the keys to ensuring that Georgia taxpayers are not overpaying for Medicaid services, which is critical at all times but especially when demand for Medicaid services is so high and public monies to pay for Medicaid are scarcer than ever.”

DCH Inspector General Robert Finlayson stated “the Georgia Department of Community Health continues to aggressively identify fraud and abuse in our Medicaid program.  Our collaborative efforts with the Georgia Medicaid Fraud Control Unit allow us to effectively safeguard taxpayer dollars and ensure these dollars are being used to provide health care services to Georgia’s most vulnerable populations. Reviews of other hospitals for similar billing issues are on-going and any identified will be referred to the Fraud Unit for further investigation. Hospitals that have themselves identified billing errors are encouraged to self-report the information pursuant to Medicaid Policy.”

Senior Assistant Attorney General Scott Smeal led the investigation for the state, assisted by auditors and investigators with the Georgia Medicaid Fraud Control Unit.