Monthly Spotlight on Fraud, Waste, and Abuse
Date Posted: Tuesday,
January 14, 2025
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.
Although UCHealth entered this health care fraud settlement with the United States, it refused to agree to compliance-related oversight with HHS-OIG through a Corporate Integrity Agreement. Therefore, as part of the Settlement Agreement, OIG reserved the right to exclude UCHealth for the alleged conduct resolved in the Settlement Agreement. Because UCHealth refused appropriate integrity obligations, OIG may use various tools to monitor UCHealth's compliance with the Federal health care programs.
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, accepting 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.
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. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. As part of today's resolution, the private party will receive $3.91 million of the proceeds from the settlement.
The claims resolved by the settlement are allegations only. There has been no determination of liability.
Source: UCHealth Agrees To Pay $23M To Resolve Allegations Of Fraudulent Billing For Emergency Department Visits (2024, November 12). www.justice.gov
Florida Ophthalmology Practice Agrees to Pay $1.3M to Resolve Allegations of Fraudulent Claims for Cranial Ultrasounds
Brandon Eye Associates P.A. (Brandon Eye), an ophthalmology practice with offices in Brandon, Sun City and Plant City, Florida, has agreed to pay $1.3 million to resolve alleged violations of the False Claims Act and an analogous Florida statute arising from its billing for trans-cranial doppler ultrasounds (TCDs) provided through a kickback arrangement with a third party. Brandon Eye has agreed to cooperate with the Justice Department's investigations of other participants in the alleged scheme.
The settlement announced today resolves allegations that Brandon Eye knowingly submitted and caused the submission of false claims for medically unnecessary TCDs performed on Brandon Eye's patients. Brandon Eye and a third-party provider of turnkey mobile TCD services, through an agreement, performed TCDs on Brandon Eye patients who had been diagnosed with common health conditions such as diabetes, hypertension and glaucoma. Before the patient received the TCD result, Brandon Eye and the third-party provider identified the patients as having received a serious diagnosis - most commonly of occlusion and stenosis of their cerebral arteries - that could qualify the patient for reimbursement of a TCD by Medicare or Medicaid. However, nearly all patients who received TCDs never had occlusion and stenosis of cerebral arteries, and that diagnosis was accordingly not reflected in the patient's medical history or in the TCD results. For each TCD ordered for each Medicare Part B patient, Brandon Eye claimed reimbursement for the technical component of the test, paid the third-party TCD provider based on the volume or value of tests ordered, and referred the patient to the TCD provider's preferred radiology group for the TCD's professional component.
The United States alleged that because of this scheme, Brandon Eye submitted, or caused the submission of false claims to Medicare and Medicaid for TCDs that were medically unnecessary, that were premised on false diagnoses, and that resulted from violations of the Anti-Kickback Statute and the Stark Law. Of the $1.3 million total settlement amount, $1,210,245.70 is to be paid to the United States, and $89,754.30 is to be paid to the State of Florida for its share of Medicaid, which is a jointly funded federal and state program.
The claims resolved by the settlement are allegations only. There has been no determination of liability.
Source: Florida Ophthalmology Practice Agrees to Pay $1.3M to Resolve Allegations of Fraudulent Claims for Cranial Ultrasounds (2024, November 12). www.justice.gov
Virginia Hospital System Agrees To $2.37M False Claims Settlement
Inova Health System Foundation, Inova Health Care Services, Inc., and Inova Physician Partners, LLC, (collectively, Inova), located in Falls Church, agreed to pay $2,378,731.06 to settle claims that it submitted claims to Medicaid that contained falsified information.
Inova voluntarily submitted written disclosures to the U.S. Attorney's Office and the Virginia Attorney General's Office. Specifically, the disclosure stated that, between Jan. 1, 2020, and Aug. 31, 2020, Inova had submitted claims to Medicaid for reimbursement, including resubmitted claims for reimbursement, for sterilization and hysterectomy procedures that contained documentation that had been improperly modified by or at the request of one or more Inova employees. These modifications resulted in the claim containing falsified information. Following an internal investigation, Inova took remedial actions and agreed that $1,585,820.71 received from Medicaid was improper.
Inova received full credit under the Justice Department's guidelines for taking disclosure, cooperation, and remediation into account in False Claims Act cases.
The civil claims settled are allegations only; there has been no determination of civil liability.
Source: Virginia Hospital System Agrees To $2.37M False Claims Settlement (2024, November 15). www.justice.gov .
Laboratory Owner Charged for $79M Fraud Scheme
The owner and operator of a Texas laboratory was charged in connection with his role in a $79 million respiratory pathogen panel (RPP) testing fraud scheme. According to court documents, this man caused BioDX Labs LLC (BioDX) to submit more than $79 million in fraudulent claims to Medicare and Texas Medicaid for RPP tests that were not provided and were medically unnecessary. He used the personal identifying information of a physician, without the physician's knowledge or consent, to cause the submission of millions of dollars in claims to Medicare and Medicaid for RPP tests for beneficiaries and recipients, even though the physician had no prior relationship with the beneficiaries and recipients, was not treating the beneficiaries and recipients for respiratory symptoms, and did not use the tests to treat the beneficiaries and recipients. To conceal that BioDX did not perform the tests as billed, he falsely represented that BioDX used reference laboratories to perform its testing. He and his co-conspirators laundered the proceeds of the fraudulent scheme by transferring substantial sums to bank accounts abroad, including accounts in China, Hong Kong, Turkey, Greece, and Switzerland. In connection with the charges, the government seized over $15 million in cash.
He is charged with three counts of health care fraud, conspiracy to engage in money laundering, and three counts of money laundering. If convicted, he faces a maximum penalty of 10 years in prison on each count.
An indictment is merely an allegation. All defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.
Source: Laboratory Owner Charged for $79M Fraud Scheme (2024, November 20). www.justice.gov
