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Hospital Pays $5.3M to Settle CMP Case Over Critical Care, Admissions

Billing for inpatient admissions and critical care, a sometimes-fluid area as patients move in and out of stability, were at the heart of the University of California (UC) San Diego Health System’s $5.3 million settlement with the HHS Office of Inspector General. UC San Diego Health System agreed to settle allegations under the Civil Monetary Penalties Law that it billed Medicare, Medi-Cal and TRICARE for inpatient admissions that should have been outpatient or observation services, and charged for critical care management services without supporting documentation, according to the settlement.

UC San Diego Health System voluntarily reported problems to OIG and was accepted into its Self-Disclosure Protocol in June 2016. OIG contends UC San Diego Health System billed for critical care CPT codes 99291 or 99292 without supporting documentation from May 10, 2010, through Sept. 30, 2015. OIG also alleged the academic health system submitted claims for inpatient services it should have known were billed as outpatient or observation services from May 10, 2010, to July 19, 2015, to Medicare; from June 1, 2013, through May 9, 2016, to Medi-Cal; and from May 10, 2010, through May 6, 2016, to TRICARE. Of the settlement amount, $3.4 million is restitution, the settlement states.

In a statement, UC San Diego Health said that when it found out about its billing issues, “UC San Diego Health engaged an independent law firm to conduct an internal investigation. In addition to self-reporting these matters, UC San Diego Health promptly implemented a series of corrective actions—including governance changes, education and training, and claim processing and integrity improvements. UC San Diego Health is committed to compliance and is gratified to put this matter behind it.”

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