Compliance News Roundup: Beware of Modifier -59

1. Former Orange County lab Owner Sentenced to 8 Years for Healthcare Fraud – “A former Aliso Viejo resident was sentenced to eight years in prison on Monday for submitting fraudulent bills to insurance companies for $8 million in medical tests and services that were never performed. Michael Mirando, 40, who now resides in Portland, Oregon, was found guilty on May of 15 felony counts of healthcare fraud.” Get the full scoop >>

2. Chemed Corp. and Vitas Hospice Services Agree to Pay $75 Million to Resolve False Claims Act Allegations Relating to Billing for Ineligible Patients and Inflated Levels of Care – “Chemed Corporation and various wholly-owned subsidiaries, including Vitas Hospice Services LLC and Vitas Healthcare Corporation, have agreed to pay $75 million to resolve a government lawsuit alleging that defendants violated the False Claims Act (FCA) by submitting false claims for hospice services to Medicare. Chemed, which is based in Cincinnati, Ohio, acquired Vitas in 2004. Vitas is the largest for-profit hospice chain in the United States.” Get the full scoop >>

3. Deeper Than the Headlines: Beware of Modifier -59 – This week, we’re going to dive deep into a code and how improper use can lead to some serious financial problems for your organization. For those of you unfamiliar with coding and billing, modifier -59 is a two-digit numeric code modifier that can be appended to a CPT or HCPCS procedure code, for example, and will frequently bypass many payor edits. These edits are typically in place to prevent unbundling and overpaying of services in typical circumstances. However, as we all know, there are many exceptions in healthcare. Modifier -59 is appropriate when certain clinical circumstances are met to bypass certain edits while ensuring additional reimbursement.

But remember, medical records that describe the appropriateness of such a modifier are not typically submitted in advance with a claim. Medicare and Medicaid, for example pay providers on the trust system since providers are required to certify they will follow all the rules and submit claims appropriately. Recently, one provider, Mercy Hospital in Portland, ME settled with the government for $1.5 million to resolve allegations that they overbilled Medicare and Medicaid. The chief culprit in these allegations: Modifier -59 (the bad boy of coding). Get the full scoop >>