The former case management director at Gateway Regional Hospital in Granite City filed suit against her former employer in Madison County Circuit Court Feb. 23, alleging the hospital violated the Illinois Whistle Blower Act.
Diane Hughes claims that in July 2006, a nursing home in Granite City lost power and 51 residents of the nursing home were brought to Gateway.
Hughes alleges that Gateway's vice president of Nursing Services and the chief executive officer told her to classify the nursing home patients as "full admission inpatients" and that she and her staff were to ensure the required documentation was in the records of the patients so their accounts could be billed to Medicare, Medicaid or other insurances.
If the nursing home residents were admitted as inpatients to Gateway, then they could bill the insurances for their stay at the hospital, Hughes alleges.
She claims she informed the CEO that the nursing home residents were only there for a safe environment and there was no medical need to treat them, then they would be considered borders and Medicare, Medicaid and insurance companies could not be billed.
Hughes claims it was reiterated to her that all the nursing home residents were to be full admissions with no insurance denials and that she and her staff were expected to get the needed documentation to support that decision.
"Because it would have been fraudulent to do so, and a violation of federal law pertaining to Medicare reimbursement, Hughes did not direct her staff to obtain the documentation which she was told to get," the complaint states.
Hughes claims three out of the 51 did meet the criteria for admission and were classified as such, but the remainder were not admitted as inpatients because they did not meet the criteria for admission.
According to Hughes, on Sept. 18, 2006, she was told by her supervisor that she could either resign from employment or be terminated.
"The reason Hughes was terminated was that she refused to obtain false documentation so that the nursing home residents could be fully admitted as inpatients and billed as such," the complaint states.
She claims by requiring her to obtain false information to justify inpatient admission and billing which was not medically necessary, Gateway was requiring her to participate in an activity that would result in a violation of federal law.
Hughes claims that her termination was in retaliation for her refusal to participate in illegal activities.
Hughes claims she has lost income and benefits, suffered emotional distress, humiliation, and embarrassment, and incurred legal costs and attorney fees.
Represented by Susan Andorfer of Belleville, Hughes is seeking damages in excess of $50,000, plus costs of the suit.
The case has been assigned to Circuit Judge Barbara Crowder.
07 L 185