The owner/operator of St. Luke's Hospital-Miners Campus, Coaldale, must pay more than $1 million to the United States for what the federal government said was its submission of improper Medicare claims dating back to 2002, prosecutors said Wednesday.
St. Luke's University Health Network, Bethlehem, must pay $1,029,791 for claims that cannot be paid under the rules of the Medicare program, according to Peter J. Smith, U.S. attorney for the Middle District of Pennsylvania.
Heidi Havens, a spokeswoman for Smith, confirmed Wednesday that some of the claims arose from St. Luke's Hospital-Miners Campus.
From Jan. 1, 2002 through June 30, 2012, the network submitted claims for evaluation and management services, Smith said.
"Medicare does not normally allow additional payments for such services ... unless the service is a significant, separately identifiable and above and beyond the usual preoperative and postoperative care associated with the procedure," Smith said.
Smith said the hospital had to submit a Modifier 25 attachment with its claim in order to try to obtain compensation for evaluation and management services.
The money that the network will pay arose from claims containing such attachments, Smith said.
Smith said his office prosecuted the case because Novitas Solutions Inc., Camp Hill, which is in the Middle District, processed the claims.
Denise Rader, media relations director for the network, said Wednesday that the problem arose from complex rules involving such claims.
"Unfortunately, there has been significant confusion in the hospital industry as to when a Modifier 25 should be used. Estimates indicate that nationally as much as 35 percent of Modifier 25 submissions may have been incorrectly applied," Rader said. "Hospitals across the country are being audited and requested to refund money received including interest for incorrectly submitting evaluation and management claims with a Modifier 25 for services provided as an outpatient service in a hospital."
Rader said Smith's office recognized St. Luke's for fully cooperating in the review of the charges. St. Luke's is working with its billing intermediary to ensure that future submissions are properly coded and supported by clinical documentation, according to Rader.
The U.S. Department of Health and Human Services and the Office of the Inspector General investigated the case.