While all eyes were on last week’s vote to pursue negotiations with Cleveland Clinic to take over Indian River Medical Center, the IRMC board of directors hired a new company to run the hospital’s emergency room.

Envision, parent company of physician outsourcing giant EmCare, is the third outside company in four years to staff the medical center’s ER. The last group, Apollo, was let go in May 2016 and the hospital resumed staffing the ER with its own physicians for the first time since 2009.

The IRMC board of directors approved its patient care committee’s recommendation of Envision just weeks after the Justice Department announced the company settled a massive fraud case dating back to 2008.

The $29.6 million settlement with Envision and its ER services division, EmCare, involved the company’s contracts with the now-defunct Naples-based health system giant, Health Management Associates.

Whistleblowers alleged that the for-profit HMA was paying off EmCare doctors to admit ER patients as inpatients when their conditions didn’t warrant it. The alleged fraud cost taxpayers millions of dollars in higher Medicare costs, since Medicare pays about three times as much for inpatient care as it does for outpatient.

EmCare’s contracts were alleged to have included incentives from HMA to admit ER patients for hospital stays.

The Justice Department joined in eight suits filed under the False Claims Act involving allegations from 2008 to 2012, including some against former CEO of HMA, Gary Newsome.

The lawsuits were filed by two widely-respected emergency room doctors in the Charlotte, N.C., area, including the ER medical director at Lake Norman Regional Medical Center. Six other states were ultimately involved, as well as a second physician services group. They were the subject of a “60 Minutes” broadcast in 2012, as well as a New York Times article in 2014.

That article pointed out one hospital where doctors allegedly were given a goal of admitting 50 percent of all patients over 65 – Medicare eligible, in other words – and their success or failure to achieve that goal was charted on scorecards for all the ER physicians to see.

The good news for IRMC is that Envision will now be overseen by the Department of Health and Human Services Office of Inspector General as part of the lawsuit resolution.

IRMC spokesperson Angela Dickens, who was not aware of the Envision settlement, said the reason the hospital decided to go back to a contracted physicians services company is that IRMC has been unable to fill the post of emergency department director due to the uncertainty of ongoing employment once a new hospital partner takes over.

Currently IRMC is in exclusive negotiations with the Cleveland Clinic, hoping to reach a definitive acquisition agreement by late spring.

EmCare, one of the largest physician outsourcing companies in the nation currently provides ER staff for HCA’s Lawnwood Regional Medical Center in Fort Pierce and HCA’s St. Lucie Medical Center in Port St. Lucie. In all, its services are contracted by 55 Florida hospitals.

Emergency rooms are a key access point for hospitals nationwide, with 4 million people a year relying on their on-the-spot care.

As IRMC has struggled for patient revenues, much of its patient outmigration – people opting for a competitor hospital like Sebastian River or Lawnwood – has been blamed on bad experiences in the ER, with long wait times historically topping the list of complaints.

The scenario was at its worst five years ago, when the ER was staffed and operated by Emergency Physicians of Central Florida, which charged IRMC a flat fee of $890,000 a year, over and above doctors’ pay. In 2013, wait times averaged 46 minutes to see a healthcare professional such as a triage nurse – twice the national average – and six-and-a-half hours before admission. That year, 1,600 patients left the Vero ER without ever being seen – 3.4 percent of the hospital’s 58,000 ER patients.

The hospital fired Emergency Physicians of Central Florida, which had been running the ER since 2009, and hired an Atlanta group called Apollo, paying them a fee based on performance instead of a set amount.

Wait times improved slightly in 2014, but the wait to get a room after being admitted was still at five hours and 45 minutes – much worse than the Florida and national average of around four-and-a-half hours. Both Sebastian River and Lawnwood beat those average times.

In May 2016, IRMC stopped using Apollo and went back to staffing the ER with its own physicians. Envision took over Feb. 1.

IRMC’s most recently available wait times are from January to March of last year, when it took 16 minutes to be seen by a healthcare professional, about the same as the state average and less than the national average of 27 minutes.

The wait from arriving at the ER to being admitted to a patient ward was five hours, still greater than the state and national averages but an improvement of 35 minutes compared to IRMC’s average from 2014 to 2016.

Saturday, wait times looked particularly good at IRMC, according to the interactive ProPublica website that tracks ER times across the country. It took only 16 minutes to see a triage nurse, as compared to 6 minutes at Lawnwood and 17 at Sebastian. After being admitted, the additional wait time to get to an inpatient bed was about two hours in Vero and Sebastian, and only an hour and a half at Lawnwood.

Cleveland Clinic Weston, the system’s only Florida hospital – so far – had wait times that beat Vero’s, but only by two minutes. The wait to get a room once admitted was far worse at Weston: three hours and 10 minutes, as compared to two hours and six minutes at IRMC.

Often, long ER wait times are due to a shortage of support staff, which can slow down delivery of lab results and X-ray readings. Staff shortages can also result in inpatient rooms being left unsupervised, and therefore unusable.

Current IRMC job openings on the Emcare.com website include emergency medicine physicians, nurse practitioners, and an emergency medicine medical director.