Home E-Weekly October 10, 2017

Spine Practice Pays $1.9M to Resolve Improper Billing Practices

Published: October 9, 2017

BY THE BOOK New York Spine & Wellness contracted with an independent billing company, but was still obligated to code its services accurately.

The New York Spine & Wellness Center in Upstate New York will pay $1.9 million to resolve claims of improper billing after federal investigators discovered the practice's physicians did not spend enough face-to-face time with patients when administering moderate sedation.

Physicians who bill for moderate sedation must spend at least 16 minutes with patients, according to the American Medical Association. The Medicare Administrative Contractor for New York that processes providers' claims confirmed the 16-minute rule in February 2012. However, New York Spine & Wellness, which has offices in and around the Syracuse area, routinely billed for moderate sedation services when its physicians spent less than the required time with patients, according to the U.S. Attorney's Office.

New York Spine & Wellness' improper billing practices surfaced in January 2015 when a private insurance company rejected a pair of the practice's claims, which did not indicate that physicians had met the 16-minute rule. A subsequent audit by the same insurer rejected additional claims for moderate sedation services when documentation failed to indicate the procedures lasted more than 16 minutes. The company asked New York Spine & Wellness to review the audit's findings, but the practice continued to bill for sedation services that did not include 16 minutes of face-to-face time with patients until the U.S. Attorney's Office began its investigation.

Healthcare providers should have policies and procedures in place to ensure that they are familiar with billing requirements before submitting claims, according to the U.S. Attorney's Office.

"New York Spine & Wellness Center, like all health care providers, must be held to a high standard of ethical behavior," says Scott J. Lampert, special agent in charge of the U.S. Department of Health and Human Services, Office of Inspector General's New York Region (HHS-OIG). "HHS-OIG will continue to ensure that providers that bill federal health care programs do so in an honest manner."

Daniel Cook

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