A whistleblower’s lawsuit against the Verona-based digital health care records giant Epic Systems alleges the company has been overbilling the government for Medicaid and Medicare.
Geraldine Petrowski, a former employee for a health care system in North Carolina, filed the lawsuit in 2015 under the False Claims Act, the U.S. government’s primary mechanism for combating fraud. Under that law, claims brought by whistleblowers are kept under seal while the Department of Justice investigates the allegations — hence why the lawsuit was kept under wraps until last week, when a federal court unsealed documents in the case.
The suit has to do with an aspect of Epic’s medical records software that lets hospitals choose how they itemize bills for anesthesia. According to the complaint, the software allows a health care provider to effectively get reimbursed twice for the same anesthesia services.
Petrowski served as a liaison between the health system, called WakeMed, and Epic. She claims that she alerted Epic to the anesthesia billing feature, and that the company eventually removed it for WakeMed. However, her complaint claims that the feature remains built into other health systems across the country.
The specifics of the billing protocol have to do with different ways of measuring how long a patient is under anesthesia. Some health care providers charge using “units” of 15 minutes under anesthesia, while others simply charge based on total minutes. The Epic feature allegedly let hospitals add units to minutes, double-charging payers for anesthesia.
“This unlawful billing protocol has resulted in the presentation of hundreds of millions of dollars in fraudulent bills for anesthesia services being submitted to Medicare and Medicaid as false claims,” reads Petrowski’s complaint.
Under the False Claims Act, whistleblowers are allowed to bring suits on behalf of the government, and are entitled to a portion of any recovered funds.
For any given claim of fraud, the Department of Justice decides whether to intervene. Epic has said in court filings that the DOJ informed them in February that it does not intend to act on the lawsuit. However, under the law, the original whistleblower is still allowed to pursue the case.
Epic’s public relations director Meghan Roh shared a statement with other media outlets who reported on the lawsuit: “The Department of Justice did its own expert review and decided not to move forward. The plaintiff’s assertions represent a fundamental misunderstanding of how claims software works.”
The lawsuit comes while another lawsuit filed against Epic Systems is pending judgment from the Supreme Court. The high court will determine whether it is lawful for companies like Epic to require workers to waive their rights to pursue wage complaints in class-action lawsuits.