Anesthesia group New York Spine and Wellness Center will pay nearly $2 million to resolve allegations that it improperly billed for moderate sedation services.

New York Spine and Wellness is a pain management practice that performs some procedures under moderate sedation. A private insurance company performed an audit of the practice’s claims for moderate sedation and found that the Medicare 16-minute face-to-face time rule had not been satisfied with the appropriate documentation, in many cases. This continued after the practice’s billing company made them aware of the audit results, according to allegations from the Department of Justice (DOJ).

The American Medical Association and the Medicare Administrative Contractor for New York confirmed that 16 minutes of face-to-face time with patients was required to bill for moderate sedation. New York Spine and Wellness spent less than 16 minutes, but billed for the underlying diagnostic or therapeutic procedure, according to the DOJ.

Although New York Spine and Wellness used a billing company, the practice was responsible for knowing the appropriate requirements of billing a certain code. This should be a wake-up call to practitioners who depend on billing companies and think their coding is compliant. 

Robert B. Vogel, MD, JD
Retinal Ophthalmologist at Piedmont Eye Center, Lynchburg VA;
Attorney, Overbey Hawkins & Wright, PLLS, Lynchburg, VA;
Adjunct Professor, Humanities and Bioethics, Liberty University School of Medicine, Lynchburg, VA.

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