The United States Attorney’s Office District of Colorado announced on November 12, 2024 that 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.
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 Nov. 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.
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 the resolution, Mr. Sanders will receive $3.91 million of the proceeds from the settlement.
If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publicly known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.
Visit our website or call us toll-free in the United States at 800-295-3959 to be connected with qui tam lawyers (False Claims Act lawyers) in your U.S. state who may assist you with a False Claims Act lawsuit.
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