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Government-run healthcare systems, such as Medicare and Tricare, depend on honest reporting regarding services provided to patients. While some procedures are fairly straightforward, others are slightly more ambiguous, potentially opening the door for potential fraud. Certain codes relate to the Evaluation & Management (E&M) of covered individuals. According to the Department of Justice, a large medical system in Colorado used a fraudulent standard to increase what they received from the government. 

The University of Colorado Health (UCHealth) agreed to pay $23 million based on accusations that their system of E&M coding violated the federal False Claims Act (FCA). Between November 1, 2017, and March 31, 2021, UCHealth facilities allegedly assigned a high-level E&M code—CPT 99285—for emergency room visits based solely on the frequency of vital sign checks, even if the patient’s actual condition did not justify that designation. Specifically, the code was applied when vital signs were checked more times than the total hours the patient spent in the emergency department, except in cases where patients were present for fewer than 60 minutes.

CPT 99285 is reserved for cases involving high complexity and significant resource use, such as patients requiring urgent intervention for life-threatening or serious medical conditions. By assigning this code automatically without accounting for actual medical necessity or the intensity of care provided, UCHealth allegedly inflated claims submitted to federal health care programs.

Pursuant to the qui tam provision of the FCA, Timothy Sanders filed a lawsuit on the government’s behalf concerning UCHealth’s improper coding practices. As a result, Sanders will be eligible to collect a portion of the $23 million settlement payment made to the government. 

When hospitals and other medical providers fail to comply with billing standards, employees are typically the people in the best position to detect malfeasance. Automated processes such as the one used by UCHealth can lead to years of fraud before someone notices. If you suspect improper billing or other violations, consult a knowledgeable attorney at Kardell Law Group to protect your rights and address potential issues proactively. We can advise you regarding the potential success of a qui tam lawsuit and represent you during settlement negotiations and in court if you decide to move forward.