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Coding & Compliance Tip

Yesterday we saw another $1.2 million dollar enforcement against a provider inappropriately using Modifier -25. At some point we need to put this issue to bed. We are far past the days where providers can stick their head in the sand and say "I didn't know". Dwindling are the days of "pay and chase". Many plans are putting providers on prepayment review when this issue is prevalent in their claims data. I attended the NHCAA national conference a few months ago and the health plans are seeing staggering savings by implementing prepayment review models and, they are sharing information. Q: Why are 25, and 59 the most frequently used (abused) modifiers? A: Because they bypass NCCI edits on the health plan side and trigger payment. Still not convinced? Here is some great bedtime reading. 31 U.S.C. § 3729. While the False Claims Act imposes liability only when the claimant acts “knowingly,” it does not require that the person submitting the claim have actual knowledge that the claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information, also can be found liable under the Act. Now you know...

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