On April 20, 2021, the Department of Justice announced that Massachusetts Eye and Ear, a Boston hospital, agreed to pay over $2.6 million to resolve allegations that it improperly used the “Modifier 25” billing code to obtain higher reimbursements from Medicare and Medicaid.
Typically, when a Medicare or Medicaid beneficiary visits a physician to have a procedure performed, the physician can bill only for the procedure. If, however, the patient’s condition requires a significant, separately identifiable evaluation and management office visit, above and beyond the usual pre and post-operative care associated with the procedure or service performed, then the provider may bill for that visit, too, by referencing Modifier 25 along with the procedure billing code on the Medicare or Medicaid claim form.
According to the government’s allegations in the settlement agreement, Massachusetts Eye and Ear submitted “fee-for-service claims to Medicare Part B and MassHealth for office visits in conjunction with claims for nasal endoscopies and laryngoscopies, when otolaryngologists did not actually perform significant and separately identifiable evaluation and management services during the period from January 1, 2012 through February 1, 2020.”
Fraud and abuse involving Modifier 25 have been long-running. In 2005, the Department of Health and Human Services Office of Inspector General released a report on Modifier 25: after conducting an audit of 450 claims billed in calendar year 2002 using Modifier 25, it found that “thirty-five percent of claims using modifier 25 that Medicare allowed in 2002 did not meet program requirements.” Thus, the settlement with Massachusetts Eye and Ear is just the latest example of health care providers abusing this billing code to obtain undeserved additional reimbursement from Medicare and Medicaid.
As part of the settlement, Massachusetts Eye and Ear agreed “not to make or permit to be made any public statement denying, directly or indirectly, any” of the government’s allegations.
GREGG SHAPIRO REPRESENTS WHISTLEBLOWERS NATIONWIDE, INCLUDING IN CASES INVOLVING FRAUDULENT HEALTH CARE BILLING. HE CAN BE REACHED AT firstname.lastname@example.org or 781-808-6789.