Skyline Urology: The Modifier 25 Settlement Behind the Extra Visit

In the Skyline Urology Modifier 25 settlement, the practice agreed to pay $1.85 million to resolve allegations that it billed Medicare for routine evaluation and management services already included in same-day procedures. The alleged extra visit was work the procedure payment already covered. For a urologist, coder or billing employee, that puts the question close to home: what additional care justified the additional charge?

The Justice Department announced the settlement on February 25, 2019. Its allegations covered claims from January 1, 2013 through December 31, 2016. The resolution also required regular monitoring of Skyline’s billing practices.

What Did Skyline Urology Allegedly Bill Medicare For?

Skyline allegedly used Modifier 25 to unbundle routine evaluation and management services from urological procedures performed on the same day. Evaluation and management, usually called E/M, is the clinical work represented by the added visit charge. The government’s allegation was that Skyline claimed separate Medicare compensation for work that belonged inside the procedure’s payment.

Medicare generally prohibited separately billing same-day E/M services unless they were significant, separately identifiable and beyond the usual care before and after the procedure. Modifier 25 represented that additional work on the claim. Adding the modifier was the billing assertion. The actual care had to support it.

Medicare’s 2026 coding guidance makes the same distinction: a new-patient designation or a different diagnosis alone does not establish a separately identifiable service. The routine decision to perform a minor procedure is also included in that procedure’s payment. For a billing employee, the question is what evaluation went beyond the decision to proceed. The clinical record needs to explain the work behind the extra charge.

The Extra Service Comes Before the Visit Level

The Skyline allegation concerned whether an additional E/M service was separately payable at all. Upcoding a visit’s level concerns how much work or complexity the claim represents. For someone reviewing the bill, these are different questions: what earned the separate payment, and what earned the level charged?

Both allegations appeared in the Toccoa Clinic Medical Associates settlement. The Justice Department alleged that the practice and two physicians billed E/M services on procedure days without significant, separately identifiable work, and also billed higher visit levels than the records supported. Skyline’s announced allegation focused on the extra service. Toccoa shows why reviewing only the level can leave the more basic payment question unanswered.

In the alleged Skyline arrangement, Medicare was asked to pay for routine procedural care, then pay for it again when it reappeared as a visit. Same care. Two bills. We want to hear from the person who understands how the encounter became that extra charge.

The Settlement Required Billing Review

Skyline entered a three-year integrity agreement with the Health and Human Services Office of Inspector General requiring regular monitoring of its billing practices. The inspector general’s entry for the agreement classifies it as claims review.

This billing issue had drawn scrutiny well before Skyline’s settlement. In a November 2005 report examining claims from 2002, the inspector general found that 35% of allowed Modifier 25 claims failed Medicare’s requirements. A payment record shows what was allowed, and the chart shows what supported it.

How Much of a Settlement Does a Whistleblower Get?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The Justice Department’s Skyline announcement said the consulting firm’s founder would receive a whistleblower reward as part of the resolution.

A healthcare consulting firm’s founder brought the Skyline Urology qui tam case, and the government later joined it. That outside consulting role matters to readers who understand how health care claims are produced and reviewed. You may know the billing process from work outside the treatment room, including how a practice turns an encounter into a claim.

What an Insider Can Explain About the Claim

An insider’s account can connect the extra E/M charge to the care, the billing instructions and the people who controlled the claim. We examine the clinical and billing records together: the procedure note, the evaluation documented for the same date, and the instruction or system behavior that produced a separate charge. Your knowledge of how those records were made can explain why they agree or why they do not.

The 2017 Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse recommends comparing treatment dates, treatment types and nurse or physician signatures. It also emphasizes witnesses who can explain what happened. For an extra-visit allegation, that means understanding the work behind the documentation and how it became a separate Medicare bill.

There is an organizational question too: who had the power to change the billing? The chapter Implementing a Physician Practice Compliance Program, published in Health Care Administration: Managing Organized Delivery Systems by Jones and Bartlett Publishers in 2011, makes a distinction a practice employee may recognize immediately:

The chapter explains that assigning responsibility without the authority to act hampers the employee’s ability to carry out the task. In a billing case, we want to understand who identified a problem, who received that information and who could authorize a correction. A practice employee may know the answers even when the clinical note says nothing about those decisions.

Your Knowledge of the Added Charge

If you know why routine procedure care kept producing a separate Medicare visit charge, speak to one of our Whistleblower Experts about how those charges were built. We work with you on the care, the claims and the decisions inside the practice, and bring in healthcare billing whistleblower lawyers who understand same-day procedure claims. We stay beside you through the process to build your strongest whistleblower case.