A former nurse at Regional Medical Center in San Jose, Calif., filed a federal lawsuit alleging the hospital and its owner, Nashville, Tenn.-based HCA Healthcare, submitted false claims to Medicare.
Three things to know:
1. The lawsuit, which was filed in 2017 and recently unsealed, alleges Regional Medical Center and HCA billed for certain services on an inpatient basis when the patients were still waiting in the ED.
"The Regional Medical Center is frequently out of beds in its units and the emergency department is frequently well over capacity," the complaint states. "When this happens, patients that have been admitted to the hospital from the emergency department are left waiting in the emergency department. These patients that are admitted into fabricated room but that are still physically waiting in the emergency department for a bed in their admitted unit are known as 'holds.'"
2. The whistle-blower alleges that claims submitted to Medicare on an inpatient basis while the patient is still in the ED are fraudulent.
"When emergency department nursing staff chart patients as if the patient is located in the ICU, medsurge or telemetry units, [Medicare audit contractors] and other government claims processers have no way of knowing that the patient was physically located in the emergency department. Thus, any claims for 'holds' that seek reimbursement at greater than emergency department rates are fraudulent," the complaint states.
3. According to the complaint, hospital administrators also directed staff to upcode claims to inflate reimbursement.
"Placing the ER patients in fraudulent rooms allows defendants to upcode as many revenue codes and revenue code units on the UB04 forms and make the final bill as high as possible," the complaint states. "Defendants then benefit by receiving additional outlier reimbursements that they would otherwise not qualify for under CMS' standards."
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