Florida practitioners agree to pay $1.7M to resolve false claims case
FWC Urogynecology, a network of practitioners in Florida, agreed to pay $1.7 million to resolve allegations that it violated the False Claims Act.
U.S. Attorney Maria Chapa Lopez alleged the healthcare company knowingly billed the government for inflated prices and for services it did not provide.
FWC Urogynecology reportedly used Medicare billing codes with modifier 25, which allows providers to get additional payments for non-billable same-day services.
The settlement agreement alleged that FWC Urogynecology knowingly billed modifier 25 for additional payments between Feb. 1, 2012 to Jan. 12, 2017. One example given in the document was that physicians performed and charged for lavage treatments and pelvic floor therapies and then billed modifier 25 to make it look like they performed additional medical services.
The settlement resolves a case involving a former employee of an FWC Urogynecology provider. The employee, Holly Loebl, will receive $306,000 of the proceeds from the settlement.
Modifier 25 is a code that can cause confusion. Payers believe that providers may abuse it and providers think that payers like Medicaid do not recognize it. The American Academy of Pediatricians (AAP) said Modifier 25 is the most important modifier for pediatricians. However, AAP warned doctors to make sure they use it correctly. AAP said Modifier 25 “allows for more efficient use of your time and may save the patient another visit."
Earlier this year, Anthem announced it was going to cut payments for modifier 25 billed services by 25%. The payer initially planned on a 50% payment cut, but lessened the cut after opposition from the American Medical Association.
The AMA House of Delegates voted against the payment cut. AMA President David Barbe called Anthem’s actions unfair and “detrimental to physicians who are trying to practice medicine according to the needs of their patients.”
Anthem ultimately decided not to cut the payment after all. Dr. Craig E. Samitt, EVP and chief clinical officer of Anthem, said at the time that the payer still believes that physicians are using modifier 25 to duplicate payments, but added “the company believes making a meaningful impact on rising healthcare costs requires a different dialogue and engagement between payers and providers."
The U.S. Department of Justice also worries that providers are improperly using codes. For instance, DOJ investigated whether providers overused primary prevention implantable cardioverter defibrillators, which didn’t meet the CMS’ National Coverage Determination criteria. The DOJ reached settlements with more than 500 hospitals for more than $280 million in total Medicare claims not meeting the criteria.
ICD contains about 55,000 unique billing codes and changes are the on the way. ICD-11 was released by World Health Assembly in June, expected to go into effect in 2022.