The U.S. Attorney’s Office for the District of Massachusetts recently announced that Ophthalmic Consultants of Boston, Inc. (OCB) agreed to pay $3,902,588.28 to resolve federal and state False Claims Act (FCA) claims involving office-visit billing on the same day as intravitreal injections. OCB is a multispecialty ophthalmology practice with locations throughout Massachusetts. The matter arose from a qui tam action.
Medicare generally includes evaluation and management (E&M) work performed on the day of an intravitreal injection in the procedure’s global payment. A separate E&M service may be billed with Modifier 25 only when the service is significant and separately identifiable from the injection. MassHealth applies a similar limitation. The DOJ claimed that OCB submitted Modifier 25 claims when its documentation did not support separate billing or its ophthalmologists did not perform a significant, separately identifiable E&M service.
DOJ credited OCB under its FCA disclosure, cooperation, and remediation guidelines. The agreement identifies OCB’s acceptance of responsibility, assistance with the federal and state damages analysis, and significant improvements to coding- and documentation-compliance practices and controls. OCB also agreed to cooperate fully and truthfully with investigations of individuals and entities not released by the settlement.
GWB represents healthcare providers in connection with government investigations and False Claims Act litigation. If you need assistance with such a matter, contact us today.
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