Issue link: https://beckershealthcare.uberflip.com/i/976338
57 CODING & BILLING Anthem halts controversial modifier 25 reimbursement policy By Angie Stewart A nthem Blue Cross Blue Shield won't proceed with a policy that would have slashed reimbursement rates for evaluation and management services billed with modifier 25 by 50 percent. Here are four insights. 1. The policy would have reduced payments for evaluation and management services provided the same day as a pro- cedure or wellness exam from 50 percent to 25 percent. An- them had planned to implement the policy beginning March 1 to eliminate duplicate payments thought to be occurring. 2. Anthem's Executive Vice President and Chief Clinical Of- ficer Craig Samitt, MD, announced the policy reversal Feb. 23 in a letter to the American Medical Association. 3. "While Anthem is confident that duplication of payment for fixed/indirect practice expenses exists when physicians bill an E/M service appended with modifier 25 along with a minor surgical procedure (0 or 10 day global) performed on the same day, the company believes making a meaning- ful impact on rising healthcare costs requires a different dialogue and engagement between payers and providers," Dr. Samitt stated in the letter. 4. Anthem's decision came after a coordinated effort by sev- eral organizations, including the California Medical Associa- tion, AMA and American Association of Dermatologists, to maintain the non-reduced rate. n CMS terminates Medicare benefits of Lags Surgery Center Oxnard — 6 insights By Eric Oliver C MS terminated its Medicare provider agree- ment with Lags Surgery Center Oxnard (Calif.) at 12:01 a.m., Feb. 15. Here's what you should know. 1. CMS found the Oxnard-based surgery center was "not in compliance with regulatory requirements for participation as an Ambulatory Surgery Center in the Medicare Program." 2. CMS no longer provides payment for services to Medicare and/or Medicaid beneficiaries. 3. Lags Medical Centers is a pain management group with 20 California locations and two Oregon locations. 4. Lags has seven physicians on staff. 5. Francis Lagattuta, MD, is the medical director for Lags Medical Centers. He has more than 20 years of experience. 6. Lag's Oxnard location focuses on diagnosing and treating chronic pain. n Dr. Salomon Melgen gets 17 years in prison for defrauding Medicare at least $73M: 5 insights By Shayna Korol S outh Fla.-based ophthalmologist Salo- mon Melgen, MD, received a 17-year sentence for stealing at least $73 mil- lion from Medicare, the SunSentinel reports. Here are five things to know. 1. Dr. Melgen has been convicted of 67 crimes, including healthcare fraud, submit- ting false claims and falsifying records in patients' files. He has been in custody since his April 28, 2017 conviction. 2. According to the prosecution, he became the highest-paid Medicare physician in the U.S. between 2008 and 2013 by giving elderly patients unnecessary tests and treatments. 3. Prosecutors argued while any physician could make occasional billing mistakes, Dr. Melgen made too many. Among other things, he frequently billed Medicare for tests and treatment on the nonexistent eyes of one-eyed patients. He also split single-use vials of an expensive eye drug into four doses when there was enough extra medicine in each, billing Medicare separately for each injection. 4. Dr. Melgen was ordered to pay $42.6 mil- lion in restitution to Medicare; he could be ordered to pay more in the future. 5. Dr. Melgen became politically active in 1997 after treating Florida Governor Lawton Chiles, who appointed him to a state board. Dr. Melgen began host- ing Democratic fundraisers at his home and befriended Senator Bob Menendez, D-N.J. In a separate trial, Dr. Melgen was accused of bribing the senator, paying for trips they took to France and his home at a resort in the Dominican Republic; Sen. Menendez reimbursed Dr. Melgen $58,500 after the trips became public knowledge. 6. In exchange for the gis, Sen. Menendez allegedly interceded with Medicare officials investigating Dr. Melgen's practice, obtained visas for Dr. Melgen's foreign mistresses and pressured the State Department to intervene in a business dispute Dr. Melgen had with the Dominican government. n