HCA: Unordered LDL Tests and Duplicate Fetal Testing

HCA agreed to pay $2 million in the HCA laboratory testing settlement over allegations that four Florida hospitals billed for unordered or medically unnecessary direct-count LDL tests, and that one also double billed fetal testing. An HCA employee brought the case. The alleged bills put taxpayers on the hook for tests no one ordered or a service already included in another charge.

The settlement, announced in November 2015, was with the United States and Florida. The hospitals were West Florida Hospital, Oak Hill Hospital, Regional Medical Center Bayonet Point and Medical Center of Trinity. The government attributed the LDL claims to all four and the fetal-testing claims to the Trinity hospital.

What the HCA Laboratory Claims Were About

The government accused HCA of billing for LDL tests no one ordered or patients did not need, and of billing one fetal test twice. The first allegation turns on the order and the patient’s medical need. The second turns on what the hospital had already billed.

Direct-Count LDL Tests Without an Order or Medical Need

The United States and Florida alleged that HCA submitted direct-count LDL laboratory claims when the tests were not ordered, not medically necessary, or both.

Under Medicare’s ordering and documentation rule, the clinician keeps the reason for the test in the patient’s medical record. The billing entity keeps the information it received and support showing that its claim reflects it.

The clinical reason for a test can therefore sit outside the billing file. We connect the information the clinician supplied with the service the laboratory performed and the claim that followed.

Fetal Testing Billed Twice

HCA allegedly claimed payment for a fetal biophysical profile with a non-stress test under CPT code 76818, then submitted another claim for a standalone non-stress test under CPT code 59025. The government identified that conduct at the Trinity hospital from January 1, 2007 through September 26, 2014.

The non-stress test was already included in the profile HCA billed. According to the government’s allegation, the hospital charged for it again as a standalone service.

A billing employee who knows what the profile includes may see the overlap immediately. We examine that relationship between the broader service and the separate charge, alongside the records of the care actually provided.

Comparing HCA’s Orders and Claims

The HCA allegations call for comparing the LDL order and medical need documented in the patient’s chart with the direct-count LDL claim. For the fetal-testing allegation, the comparison is between the non-stress test already included in CPT 76818 and the additional CPT 59025 charge.

The HCA investigation began with an employee’s qui tam case under the False Claims Act.

HCA’s Earlier Laboratory Billing Allegations

HCA had already agreed to pay more than $95 million to resolve civil claims over its outpatient laboratory billing practices, according to the Justice Department’s December 2000 announcement.

The earlier outpatient laboratory allegations involved claims to Medicare, Medicaid, TRICARE and the Federal Employees’ Health Benefits Program. They concerned tests the government said physicians had not ordered or patients did not need, along with other laboratory billing violations.

In the later Florida settlement, HCA faced those same kinds of allegations again, this time over direct-count LDL testing.

The HCA Whistleblower Reward

The Justice Department said the HCA employee who brought the case would receive a 20% whistleblower reward from the settlement funds.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know the Order Behind the Charge

If you work with hospital test orders or billing and recognize an unsupported test or a charge for a service already included, speak to one of our Whistleblower Experts about the tests that should never have been billed. We build your strongest laboratory fraud whistleblower case with you, bring in whistleblower lawyers who understand healthcare billing and laboratory orders, and stay beside you through the pursuit of a recovery.