Seton Shoal Creek Hospital Agreed to Pay $2.4 Million for Allegedly Violating the Civil Monetary Penalties Law by Paying Remuneration to Beneficiaries by Waiving Coinsurance and by Submitting Claims for Services that Lacked Physician Certification

After it self-disclosed conduct to OIG, Seton Family of Hospitals d/b/a Seton Shoal Creek Hospital (Seton), Texas, agreed to pay $2,474,008.76 for allegedly violating the Civil Monetary Penalties Law (CMPL) and provisions of the CMPL applicable to kickbacks. OIG alleged Seton paid remuneration to Medicare beneficiaries in the form of waiving collection of beneficiary coinsurance and deductible amounts. OIG further alleged that Seton presented claims to Medicare for items or services that it knew or should have known were not provided as claimed and were false or fraudulent. Specifically, OIG contended that Seton submitted claims for partial hospitalization program (PHP) services that did not meet Medicare requirements in that: (1) claims were submitted where patients had been admitted without a proper certification by the physician that the patient would require inpatient psychiatric hospitalization if not admitted to the PHP program requiring at least 20 hours of therapeutic services through the PHP on a weekly basis;( 2) claims were submitted where the physician treating the patient failed to recertify the patient's ongoing need for PHP services; and (3) claims were submitted where PHP patients did not have individualized treatment plans, prescribed and signed by a physician, which identified treatment goals, described coordination of services, were structured to meet the particular needs of the patient, included a multidisciplinary team approach to care, and documented ongoing efforts to restore the patient to a higher level of function that would permit discharge from the PHP or reflected the continued need for the intensity of the active PHP therapy to maintain the individual's condition and functional level to prevent relapse or hospitalization.

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