Main Line Hospitals Agree to Pay Government $1,030,540
To Resolve Allegation of Improper Medicare Claims
The United States Attorney's Office for the Middle District of Pennsylvania announced that Main Line Hospitals, Inc. has agreed to pay the United States $1,030,540 to resolve allegations that it erroneously submitted improper claims to the Medicare program. Main Line Hospitals owns and operates Bryn Mawr Hospital, Lankenau Medical Center, Paoli Hospital, and Bryn Mawr Rehabilitation Hospital; all located in suburban Philadelphia.
According to United States Attorney Peter J. Smith, Main Line Hospitals has agreed to pay $1,030,540 to resolve allegations that from January 1, 2004, through February 28, 2011, Bryn Mawr Hospital, Lankenau Hospital, and Paoli Hospital 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 Main Line’s hospitals incorrectly attached Modifier 25 to Medicare claims that led Medicare to pay the hospital for evaluation and management services that were not significant and separately identifiable from the underlying procedure for which Medicare also paid the hospital.
The U.S. Attorney’s Office acknowledged and credited Main Line’s cooperation and remedial action which helped to resolve the matter efficiently. After the Government contacted Main Line concerning improper Modifier 25 claims at Paoli Hospital, Main Line voluntarily brought in an outside auditor to review similar claims submitted by its other member hospitals and disclosed that Bryn Mawr Hospital and Lankenau Hospital had also submitted improper Modifier 25 claims to the Medicare Program.
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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