Mass. Eye and Ear Settles FCA Case; Patient Was the Whistleblower

By Nina Youngstrom

Massachusetts Eye and Ear Infirmary, Massachusetts Eye and Ear Associates Inc., and the Foundation of the Massachusetts Eye and Ear Infirmary Inc. agreed to pay $2.678 million to settle false claims allegations set in motion by a patient with commercial insurance, the Department of Justice (DOJ) said April 20.[1] The defendants, referred to collectively as Massachusetts Eye and Ear, allegedly billed Medicare and Medicaid for evaluation and management (E/M) services that were not “significant and separately identifiable” from nasal endoscopies and laryngoscopies performed on the same patients.[2]

According to the settlement, Boston-based Massachusetts Eye and Ear Infirmary is a not-for-profit teaching hospital, Massachusetts Eye and Ear Associates is a medical group, and the Foundation of Massachusetts Eye and Ear Infirmary is the parent corporation for these and other organizations. They were hit by the False Claims Act (FCA) lawsuit in April 2018 after a patient, Benjamin Schwarz, didn’t like what he saw on his explanation of benefits (EOB) form. Schwarz didn’t think it accurately described services he received from a Massachusetts Eye and Ear physician, he alleged in the complaint. Schwarz informed both his insurer and the providers but was unsatisfied with their responses, which left him with a relatively small bill that eventually turned into a whistleblower complaint.

DOJ and the state allege that Massachusetts Eye and Ear billed Medicare Part B and Massachusetts Medicaid (MassHealth) for office visits in addition to nasal endoscopies and laryngoscopies, “when otolaryngologists did not actually perform significant and separately identifiable evaluation and management services during the period from January 1, 2012 through February 1, 2020,” the settlement explains. “To signify an otolaryngologist’s provision of a significant and separately identifiable evaluation and management service, a hospital’s claim must contain a Modifier 25 code, in addition to a Current Procedural Terminology evaluation and management service code.”

This document is only available to subscribers. Please log in or purchase access.
Purchase Login
 


Would you like to read this entire article?

If you already subscribe to this publication, just log in. If not, let us send you an email with a link that will allow you to read the entire article for free. Just complete the following form.

* required field

First name field cannot be blank!
Last name field cannot be blank!
We will send you an email that will give you access to this entire article.
Email field cannot be blank!
Enter a valid email!
Company field cannot be blank!
Enter a valid company!
Title field cannot be blank!

We're committed to your privacy. The Society of Corporate Compliance and Ethics (SCCE) & Health Care Compliance Association (HCCA) uses the information you provide us to contact you about our relevant content, products, and services. For more information, check out our Privacy Policy.


About SCCE

The Society of Corporate Compliance and Ethics (SCCE) is a non-profit, member-based professional association. SCCE supports our members' work with education, news, and discussion forums. We are a community of leaders, defining and shaping the corporate compliance environment across a wide range of industries and geographic regions. In developing and maintaining effective ethics and compliance programs, our members strengthen and protect their companies.

952.933.4977

About HCCA

The Health Care Compliance Association (HCCA), is a 501(c)6 non-profit, member-based professional association. HCCA was established in 1996 and is headquartered in Minneapolis, MN. We provide training, certification, and other resources to over 10,000 members. Our members include compliance officers and staff from a wide range of organizations, including hospitals, research facilities, clinics and technology service providers.

952.988.0141

Facebook Twitter LinkedIn
Copyright © 2024 by Society of Corporate Compliance and Ethics (SCCE) & Health Care Compliance Association (HCCA). No claim to original US Government works. All rights reserved. All information provided through this site, including without limitation all information such as the “look and feel” of the site, data files, graphics, text, photographs, drawings, logos, images, sounds, music, video or audio files on this site, is owned and/or licensed by SCCE & HCCA or its suppliers and is subject to United States and international copyright, trademark and other intellectual property laws. Any third party logos and/or content provided herein is owned by such third parties and is used by permission herein. Your use of this site to is subject to our Terms Of Use and Privacy Statement.
Cookie settings