Opinion ID: 4518720
Heading Depth: 2
Heading Rank: 3

Heading: The Allegations in Winter’s Complaint 4

Text: Winter, a registered nurse, became the Director of Care Management and Emergency Room at Gardens Regional in August 2014, and came to the job with thirteen years of experience as a director of case management at hospitals in Southern California and Utah. Winter reviewed hospital admissions using the admissions criteria adopted by Gardens Regional—the InterQual Level of Care Criteria 2014 (“the InterQual criteria”). The InterQual criteria, promulgated by McKesson Health Solutions LLC and updated annually, “are reviewed and validated by a national panel of clinicians and medical experts,” and represent “a synthesis of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians.” Medicare uses the criteria to evaluate claims for payment. And, as the criteria require a secondary review of all care decisions, Winter’s job included reviewing Garden Regional patients’ medical records and applying the criteria to evaluate the medical necessity of hospital admissions. In mid-July 2014, Defendant RollinsNelson—which owned and operated nursing facilities in the Los Angeles area—acquired a 50% ownership interest in Defendant S&W, the management company that oversaw operations at 4 All facts are taken from Winter’s second amended complaint. “We accept all factual allegations in the complaint as true and construe the pleadings in the light most favorable to the nonmoving party.” Outdoor Media Grp., Inc. v. City of Beaumont, 506 F.3d 895, 900 (9th Cir. 2007). 10 WINTER V. GARDENS REGIONAL HOSP. & MED. CTR. Gardens Regional. RollinsNelson then began jointly managing the hospital with S&W. When Winter started work, she noticed that the emergency room saw an unusually high number of patients transported from RollinsNelson nursing homes, including from a facility sixty miles away. The RollinsNelson patients were not just treated on an outpatient basis or held overnight for observation—most were admitted for inpatient hospitalization. In August 2014, 83.5% of the patients transported from RollinsNelson nursing homes were admitted to Gardens Regional for inpatient treatment—an unusually high admissions rate based on Winter’s experience and judgment. Winter was concerned about this pattern and scrutinized Gardens Regional’s admissions statistics, comparing July and August 2014 to prior months. She realized that the spike in admissions from RollinsNelson nursing homes corresponded with RollinsNelson’s acquisition of S&W. Not only did the number of admissions increase, the number of Medicare beneficiaries admitted rose as well. The number of Medicare beneficiaries admitted in August 2014, for example, surpassed that of any month before RollinsNelson began managing the hospital. Winter alleges that RollinsNelson and S&W—including the individual owners of both entities—“exerted direct pressure on physicians to admit patients to [Gardens Regional] and cause false claims to be submitted based on false certifications of medical necessity.” Winter’s complaint details sixty-five separate patient admissions—identified by the admitting physician, patient’s initials, chief complaint, diagnosis, length of admission, the Medicare billing code, and the amount billed to Medicare— that Winter alleges did not meet Gardens Regional’s admissions criteria and were unsupported by the patients’ WINTER V. GARDENS REGIONAL HOSP. & MED. CTR. 11 medical records. She alleges that none of the admissions were medically necessary. Winter observed several trends: i) admitting patients for urinary tract infections (“UTIs”) ordinarily treated on an outpatient basis with oral antibiotics; ii) admitting patients for septicemia with no evidence of sepsis in their records; and iii) admitting patients for pneumonia or bronchitis with no evidence of such diseases in their medical records. Winter estimates that in less than two months—between July 14 and September 9, 2014— Gardens Regional submitted $1,287,701.62 in false claims to the Medicare program. Winter repeatedly tried to bring her concerns to the attention of hospital management, with no success. In her first week, she reported the high number of unnecessary admissions to the hospital’s Chief Operating Officer. After receiving no response, she reached out to the hospital’s Chief Executive Officer. When she still received no response, she tried confronting Dr. Sacapano directly. He told her: “You know who I’m getting pressure from.” Winter understood Dr. Sacapano to mean the hospital management. At the beginning of September 2014, Defendants Rollins, Nelson and Weiner—the owners of S&W and RollinsNelson—“called an urgent impromptu meeting,” and “instructed case management not to question the admissions to [Gardens Regional.]” When Winter tried to speak up, Rollins cut her off, using profanity. Shortly after the meeting, Rollins instructed one of the hospital’s case managers to “coach” physicians, explaining in an email that “[t]hese Mds will most likely increase their admits because their documentation will be ‘assisted.’” In November 2014, Gardens Regional fired Winter and replaced her with an employee who had never questioned 12 WINTER V. GARDENS REGIONAL HOSP. & MED. CTR. any inpatient admissions. Winter filed her complaint a week later.