DENVER — UCHealth has agreed to pay $23 million to resolve allegations of fraudulent billing associated with emergency department visits, the United States Attorney's Office (USAO) for the District of Colorado announced Tuesday.
The USAO accused the health care system of violating the False Claims Act by falsely coding Evaluation and Management (E&M) claims that were submitted to Medicare and TRICARE for payment.
E&M claims document the services and resources used during certain medical visits, including visits to emergency departments. When submitting such claims, a hospital can use one of five Current Procedural Terminology (CPT) codes (CPT 99281 through CPT 99285) to describe the hospital resources used during a visit. CPT 99285 represents the highest hospital resource usage, according to the USAO.
The USAO alleged that from Nov. 1, 2017, through March 31, 2021, UCHealth hospitals falsely coded certain E&M claims for emergency room visits. In its announcement, the U.S. Attorney's Office claimed UCHealth would automatically use the CPT 99285 code when a provider checked a patient's vital signs more times than the total number of hours the patient spent in the emergency department — unless the patient was there for less than 60 minutes — no matter the "severity of the patient's medical condition or the hospital resources used to manage the patient's health and treatment."
The USAO alleged that UCHealth knew its automatic coding rule did not reasonably detail the resources used by the hospitals and, therefore, did not meet Medicare and TRICARE billing requirements.
“Fraudulent billing by health care companies undermines Medicare and other federal health care programs that are vital to many Coloradans,” said Acting U.S. Attorney Matt Kirsch for the District of Colorado in a statement. “We will hold accountable health care companies who adopt automatic coding practices that lead to unnecessary and improper billing.”
The allegations of fraudulent billing were reported by a whistleblower. Under the False Claims Act, a whistleblower can file suits on behalf of the United States, known as qui tam suits, and receive a portion of any settlement, according to the USAO. The whistleblower in this case filed a qui tam suit and will receive $3.91 million from the $23 million settlement, according to the USAO.
“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 Department of Health and Human Services Office of Inspector General (HHS-OIG) in a statement. “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 USAO said information regarding potential health care fraud, waste, abuse and mismanagement can be reported to the U.S. Department of Health and Human Services (HHS) at 800-447-8477.
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