Why the North Texas indictments matter for practices that are doing everything right — and what payer algorithms are already measuring about yours.
Federal prosecutors just indicted a group of North Texas doctors, a nurse practitioner, and clinical operators in a sweeping $25 million healthcare fraud case. The allegations include unnecessary EEGs, a Frisco-based TMS company billing TRICARE for treatments allegedly never rendered — and a Tesla Cybertruck purchased with the proceeds — and a hospice operator billing for patients who were not actually dying.
If you run a compliant interventional pain practice, your first reaction was probably relief. None of that is you.
Your second reaction should be concern. Because the enforcement climate those indictments signal does not stay contained to the obvious cases. It funds the infrastructure — investigators, algorithms, payer audit teams — that eventually works its way down to practices that are doing everything right, right up until one billing pattern flags the wrong way.
The practices we worry about most are not the ones committing blatant fraud. They are the ones whose billing tells a story they did not intend to tell.
Algorithms Do Not Read Charts. They Read Patterns.
Payers are not waiting for a whistleblower or a patient complaint. They are running automated data-mining tools against your billing history right now, comparing your coding patterns against regional baselines, and flagging statistical outliers for review.
The algorithm does not know that your documentation is clean. It does not know your patients are complex. It sees a number — the ratio of a specific modifier applied to a specific category of procedure — and it compares that number to every other practice in your MAC region. If your number looks different enough from the curve, a human reviewer gets involved. And that is when clean documentation either saves you or doesn’t.
In interventional pain management right now, the modifier drawing the most algorithmic attention is Modifier -25.
The 2023 OIG Work Plan identified Modifier -25 usage in interventional pain settings as a leading driver of improper payments — which means the scrutiny is not speculative. It is on a published federal priority list.
The Modifier -25 Landscape Has Shifted — But the Risk Has Not Gone Away
Prior authorization requirements — now extended to Medicare for most major spinal procedures — have already changed the Modifier -25 picture significantly for interventional pain. The combination patterns that once drew the most scrutiny are largely gone from compliant practices, precisely because the auth process itself requires documentation that makes same-day E/M billing clinically indefensible.
But the risk has not disappeared. It has migrated. It now concentrates around a specific subset of procedures — the minor, non-fluoroscopic work that does not require prior authorization and where the line between a legitimate E/M visit and an unnecessary one is genuinely subtle. Trigger points. Pump refills. Joint injections.
These are the procedures where a compliant practice can still have a legitimate Modifier -25 claim — and where a compliant practice can also, without realizing it, have developed a billing pattern that looks indistinguishable from abuse.
The difference between those two outcomes is not intent. It is documentation — and the pattern your documentation creates across hundreds of claims.
A Note on the TMS Case
The TMS billing alleged in the North Texas indictment involves a different mechanism than the Modifier -25 exposure we see in interventional pain — high-frequency, per-session E/M billing across a multi-week treatment protocol, a pattern that looks nothing like a pain management practice. The headline is relevant; the mechanics are not directly comparable.
What is comparable is the underlying dynamic: a billing pattern that, viewed statistically, is difficult to explain as anything other than systemic. That is what investigators look for. That is what payer algorithms are designed to surface. And that is what a practice can develop gradually, visit by visit, without anyone inside the practice ever making a single deliberately fraudulent decision.
What We See in the Data
Payer algorithms draw on published federal data to calibrate their thresholds. The CMS CERT Program (Comprehensive Error Rate Testing) continuously measures improper payment rates across modifier categories — and Modifier -25 in minor-procedure settings is among the most frequently flagged.
When we run a Modifier -25 compliance assessment for an interventional pain practice, we are looking at the same picture a payer algorithm sees — your utilization ratio across procedure types, benchmarked against regional MAC baselines. What that picture reveals, practice by practice, is that billing drift happens quietly.
A provider who legitimately needs to bill an E/M visit alongside a minor procedure in certain clinical circumstances can, over time, develop a habit of doing so in circumstances that no longer meet that bar. The documentation evolves to support the habit rather than drive it. The ratio climbs. And when it climbs past the point where it starts to look like a flat line — where every procedure visit carries an additional charge — the algorithm flags it, regardless of what the notes say.
We have seen this in practices with genuinely excellent clinicians. The billing pattern does not reflect the quality of care. It reflects the absence of someone watching the numbers the way a payer algorithm does.
What Ongoing Protection Actually Looks Like
Compliance in interventional pain billing is not a one-time chart audit. It is a continuous process of comparing what your documentation supports against what your billing pattern implies — and catching the gap before a payer does.
The clinical standard we apply derives from CMS Claims Processing Manual Chapter 12, §30.6.1 — the same standard a Medicare reviewer uses when auditing a Modifier -25 claim. Knowing that standard exists is not the same as having someone apply it to every claim before it leaves your office.
For our clients, that means pre-submission review against a consistent clinical standard for every Modifier -25 claim in the minor-procedure categories, combined with ongoing ratio monitoring against regional baselines. The standard does not change based on provider habit or scheduling pressure. If a claim does not meet it, it does not go out.
True profitability in this environment is not measured by what you bill. It is measured by what survives an audit.
Where Does Your Practice Stand?
If you do not know your current Modifier -25 utilization ratio, or how it compares to the MAC baseline for your region, that is the first thing worth finding out. Not because your practice is doing anything wrong — but because the algorithm does not know that, and it is already looking.
Our team offers a confidential, no-obligation compliance assessment for interventional pain practices. We will show you exactly what your billing pattern looks like from the outside — and what, if anything, needs to change.
Click here to schedule a confidential, no-obligation compliance assessment or reply to this post to connect with our team of certified interventional pain coding specialists.
Author Backgrou:
Resolutions Practical Consulting is a billing partner specializing in Interventional Pain Management. Our team include Practice Operation Director for pain management practices for more than 10 years.