Hospital Accused of Falsely Billing Lab Tests Agrees to $375,000 Settlement

Case: An Ohio hospital and the doctor who owns it have agreed to shell out $374,780 to settle charges of submitting false claims for prolactin and ammonia lab tests. Prolactin testing, which measures the level of prolactin in a person’s blood, is used to diagnose pituitary tumors or determine causes for conditions unrelated to psychosis or substance abuse. Ammonia testing is used to diagnose liver dysfunctions or hyperammonemia. Significance: While Medicare and Medicaid cover prolactin and ammonia lab testing, the hospital allegedly violated coverage rules in three different ways:

• The tests were performed on inpatients and thus part of the bundled DRG inpatient admission reimbursement and couldn’t be billed separately;
• Test results weren’t used to manage the patients’ condition; and
• The tests were medically unnecessary.