The United States Attorney's Office for the Middle District of Pennsylvania announced that the Lehigh Valley Health Network has agreed to pay the United States $332,479 to resolve allegations that it erroneously submitted improper claims to the Medicare program.  Lehigh Valley Health Network owns and operates Lehigh Valley Hospital, Allentown, and Lehigh Valley Hospital-Muhlenberg.

     According to United States Attorney Peter J. Smith, Lehigh Valley Health Network has agreed to pay $332,479 to resolve allegations that from January 1, 2004, through December 31, 2009, Lehigh Valley Hospital and Lehigh Valley Hospital-Muhlenberg erroneously submitted claims to the Medicare program for payment that contained evaluation and management services that were not allowable under Medicare.

     Medicare does not normally allow additional payments for such services performed by a provider on the same day as a procedure, unless the service is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure.  In such cases, an attachment to the claim, known as "Modifier 25," may be submitted to allow the additional payment.

     In this matter, the government determined that Lehigh Valley’s hospitals incorrectly attached Modifier 25 to Medicare claims that led Medicare to pay the hospitals for evaluation and management services that were not significant and separately identifiable from the underlying procedures for which Medicare also made payments.

     The U.S. Attorney’s Office credited Lehigh Valley Health Network for its positive response in this matter.  After the Government contacted the provider concerning improper Modifier 25 claims, Lehigh Valley fully cooperated with the investigation and voluntarily implemented a plan of correction that includes monitoring claims prior to submission to the Medicare program to ensure accurate coding.

     The U.S. Attorney’s Office in Harrisburg had jurisdiction because Medicare provider claims are processed by Novitas Solutions, Inc., formerly Highmark Medicare Services, in Camp Hill, Pennsylvania.  The U.S. Attorney’s Office in Philadelphia cooperated in this matter.

     The case was investigated by the U.S. Department of Health and Human Services, Office of the Inspector General in Harrisburg and handled by D. Brian Simpson, of the United States Attorney's Office, Civil Division.

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