UCHealth Agrees to Pay $23M to Resolve Allegations of Fraudulent Billing for Emergency Department Visits
University of Colorado Health, known as UCHealth and headquartered in Aurora, Colorado, has agreed to pay $23 million to resolve allegations that it violated the False Claims Act in seeking and receiving payment from federal health care programs for visits to its emergency departments, by falsely coding certain Evaluation & Management (E&M) claims submitted to the Medicare and TRICARE programs.
“Improperly billing federal health care programs drains valuable government resources needed to provide medical care to millions of Americans,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “We will pursue health care providers that defraud the taxpayers by knowingly submitting inflated or unsupported claims.”
E&M claims relate to medical visits that involve evaluating and managing a patient’s health and medical conditions, including qualifying visits to a hospital’s emergency department. In submitting an E&M claim to Medicare or TRICARE, a hospital may use one of five Current Procedural Terminology (CPT) codes (CPT 99281 through CPT 99285), depending on the hospital resources associated with the visit. An E&M facility claim coded with CPT 99285 represents the highest hospital resource usage.
The United States alleged that, from November 1, 2017, through March 31, 2021, UCHealth hospitals automatically coded certain claims for emergency room visits using CPT 99285. UCHealth used this code whenever its health care providers had checked a patient’s set of vital signs more times than the total number of hours that the patient was present in the emergency department, excepting patients who were in the emergency department for fewer than 60 minutes, despite the severity of the patient’s medical condition or the hospital resources used to manage the patient’s health and treatment. The United States alleged that UCHealth knew that its automatic coding rule associated with monitoring of vital signs did not satisfy the requirements for billing to Medicare and TRICARE because it did not reasonably reflect the facility resources used by the UCHealth hospitals.
“Fraudulent billing by healthcare companies undermines Medicare and other federal healthcare programs that are vital to many Coloradans,” said Acting U.S. Attorney Matt Kirsch for the District of Colorado. “We will hold accountable health care companies who adopt automatic coding practices that lead to unnecessary and improper billing.”
“Health care providers that participate in federal health care programs such as Medicare are required to obey laws meant to preserve the integrity of program funds, including requiring that providers submit only appropriate and accurate claims for reimbursement,” said Special Agent in Charge Linda T. Hanley of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “As this settlement demonstrates, HHS-OIG and our law enforcement partners will continue working together to protect both public safety and the integrity of our federal health care system.”
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by a private individual, Timothy Sanders. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States, et al. ex rel. Sanders v. University of Colorado Health et al., No. 21-cv-1164 (D. Colo.). As part of today’s resolution, Mr. Sanders will receive $3.91 million of the proceeds from the settlement.
The resolution obtained in this matter was the result of a coordinated effort between the Civil Division’s Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the District of Colorado, with assistance from HHS-OIG and the Defense Criminal Investigative Service.
The investigation and resolution of this matter illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477).
Trial Attorney David G. Miller of the Civil Division and Assistant U.S. Attorney Lila Bateman for the District of Colorado handled the matter.
The claims resolved by the settlement are allegations only. There has been no determination of liability.
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Source: Justice.gov
