News: $188.1M Providence Health alleged upcoding lawsuit set for potential dismissal in January

In August, the CDI world was abuzz about a lawsuit levied at Providence Health & Services, and by extension their consultant, J.A. Thomas and Associates, Inc., for allegedly upcoding various diagnoses. The thing that made this case different from other whistleblower suits was that it was brought on behalf of a data analytics firm based on the incidence of diagnoses in publicly reported data, rather than firsthand experience or chart reviews.

The firm, Austin, Texas-based Integra Med Analytics LLC, demanded a jury trial on behalf of the United States under the False Claims Act. However, according to recently released documents from the lawyers involved in the case (available via pacer.gov), the United States declined to intervene in the case and the allegations will likely be dismissed on January 14, 2019.

According to the lawyer’s reasoning for supporting dismissal, Integra is a “classic parasitic realtor” and they are “attempting to make a quick buck by using data from CMS to allege fraud.”  

Echoing some early concerns from the CDI world, the lawyers' reasoning says that, if the case was permitted to go forward, it could “give rise to a cottage industry of serial relators filing claims to extort money from healthcare providers.” The whistleblower provisions under the False Claims Act were established to reward insiders for coming forward, the lawyers wrote, rather than to support vigilante justice from outside parties.

Additionally, the allegations were based on publicly reported data alone, not on insider information and actual chart reviews. Because of this fact, the lawyers wrote that the allegations do not stand up to the public disclosure bar—meaning, since the information was already publicly disclosed, the whistleblower suit was not based on “original information” and therefore does not classify as a False Claims Act suit.

The laywers also pointed out that, since CMS was the originator of the sole data that Integra analyzed to build their case, their allegations do not tell the government anything they don’t already know and Integra cannot voluntarily disclose CMS’s data to CMS.

Editor’s note: To read about the case and the initial allegations, click here. To read about other recent whistleblower cases, click here. To read the documents about the dismissal, create an account on pacer.gov.