Fort Worth Hospital Settles Upcoding Charges for $3.3 Million

Case: A compliance officer morphed into a whistleblower when hospital leaders ignored her warnings about widespread billing and coding abuses. Specifically, she sounded the alarm that the hospital was improperly appending modifiers -25, -59 and -XU to secure improper payments. It wasn’t just a small glitch. The modifiers were misused between 70 and 95 percent of the time, meaning the hospital was essentially double billing for these kinds of claims. While not admitting liability, John Peter Smith Hospital has chosen to settle the claims for $3.3 million, $912,635 of which will go to the whistleblower.

Significance: Modifiers -25, -59 and -XU indicate that a provider delivered significant care on the same day as another medical procedure performed on the same patient. The modifier signals that the care was above and beyond the preoperative and postoperative care “bundled” into the main procedure code and should thus be reimbursed separately. In addition to allegedly misusing the modifiers on hundreds of claims, the hospital failed to reimburse payors for the resulting overpayments it received.