On November 12, the U.S. Department of Justice (DOJ) announced that University of Colorado Health (UCHealth) agreed to pay $23 million to resolve allegations that it violated the False Claims Act through fraudulent billing for emergency department visits. The settlement stems from a qui tam lawsuit filed by a whistleblower.
According to the DOJ, UCHealth “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.”
The DOJ alleges that in submitting E&M claims to Medicare or TRICARE, UCHealth automatically coded certain claims for emergency room visits using CPT 99285, which represents the highest hospital resource usage. According to the government, “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.”
“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.”
“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.”
The settlement stems from a qui tam whistleblower lawsuit filed by Timothy Sanders. Under the False Claims Act’s qui tam provisions, individuals may file lawsuits alleging government contracting fraud on behalf of the United States. In successful qui tam cases, whistleblowers are eligible to receive between 15 and 30% of the settlement.
Sanders is set to receive $3.9 million as his share of the recovery.
In July 2023, a bipartisan group of senators introduced the False Claims Amendments Act of 2023, which address a few technical loopholes undermining the success of the FCA. The bill is widely supported by whistleblower advocates.
National Whistleblower Center (NWC) has issued an Action Alert calling on Congress to pass the bill.
Join NWC in Taking Action:
Demand that Congress strengthen the False Claims Act
Further Reading:
Bipartisan Legislation Unveiled to Strengthen False Claims Act