Jan 20, 2026
Written By Elizabeth Cifers
The rules of engagement between payers and retina practices are changing quietly but quickly. Did you know there is a ‘War Room’ at the Centers for Medicare and Medicaid Services (CMS)? Officially, it is called the Fraud Defense Operations Center (FDOC), a pilot program launched in March 2025 that became permanent by June 2025. This change was mainly driven by the approximately $105 billion in savings identified through the program. While not all claims identified were in the retina space, the data show that artificial intelligence (AI) and machine learning are effective in combating potential fraud, waste, and abuse.
The efficiency with which CMS can spot irregularities suggests greater monitoring and auditing in 2026. As an auditor, one of the first things I review is the use of modifiers, which inevitably increases risk. That is not to say modifiers should not be used; they have appropriate uses, but they are easy to spot for possible coding issues. Now, oversight will be provided by algorithms trained to identify coding patterns that may be excessive, unsupported, or inconsistent. These will be sent to a human for review.
Payers are increasingly using real-time analytics and AI-assisted tools to evaluate claims against internal edits, peer norms, and historical utilization data. The manual post-payment audit we have come to know has evolved overnight into pattern detection that flags claims before payment, not after. Goodbye to ‘pay and chase’ and hello to ‘prevent and detect.’
For retina practices, this reality means one thing: every modifier carries risk if the documentation doesn’t tell a clear, defensible story. The bottom line is that every claim, every day, could be part of a live audit given the number of Additional Documentation Requests (ADRs) issued by Medicare Administrative Contractors (MACs) to review claims before payment.
Modifiers don’t change the meaning of the code they are appended to, but provide additional information about the service rendered, for example, RT to indicate the service was performed on the right eye. In retina, modifiers can indicate the eye, whether the procedure or service is related or unrelated to the global post-op, etc. They add color to the story told by the codes.
However, the story must be supported by documentation. If the documentation does not support the use of the modifier, it could be construed as fraud, waste, or abuse. The more your practice uses modifiers, the more critical your supporting documentation becomes.
Payers discover potential unusual billing behavior in the submitted claims data. Claims are analyzed for combinations of codes, utilization frequency, timing, and physician patterns that suggest something “unusual.”
Even legitimate use of modifiers can trigger automated reviews. It is no longer “if I get audited,” but “when I get audited.” For instance, as a retina practice, your data is grouped with all of ophthalmology, so it will most likely be an outlier in the CMS national data. That’s where the risk lies, because algorithms don’t understand medical context, so the documentation must explicitly provide it.
Every payer may interpret modifier use differently, and their review systems may not always be consistent with CMS or American Medical Association (AMA) guidance. Some commercial payers utilize internal rules to automatically deny claims when certain code combinations appear together, even when used correctly. Others use “behavioral edits” that trigger chart requests if the same physician consistently bills combinations that exceed statistical thresholds.
Retina practices are particularly exposed because of their workflow patterns:
These legitimate factors can mimic what payers interpret as upcoding or unbundling. Unless your documentation tells the full clinical story, i.e., why each service occurred, how it was distinct, and what decision-making supported it, the payer system sees only numbers, not nuance.
The best defense against payer analytics is your own due diligence and analytics.
Retina practices should consistently assess modifier and code utilization data by provider, payer, and location. Look for:
A quarterly (monthly is even better) internal compliance report needs to flag these trends early. Pair quantitative findings with qualitative reviews. How? Sample a few charts from each issue category to verify that documentation supports the pattern. This simple exercise can reveal weak spots before a payer’s algorithm does.
When findings emerge, use them productively, not to finger-point: reinforce education, refine templates, and adjust workflow documentation.
Internal discovery is not a failure; it’s an early warning system.
In payer audits, the narrative is the proof. Your documentation must explain, not imply, why an exception occurred. Phrases such as “separate service,” “repeat evaluation,” or “complex case” are not enough. Replace generalities with specifics tied to patient condition, clinical decision-making, or treatment sequence.
The ideal note stands on its own. A reviewer unfamiliar with the patient should be able to read the record and understand why each service occurred and how it met medical necessity. However, don’t be complacent; don't assume cloned documentation won’t be found. It will.
Governance is the connective tissue between compliance and operations.
A strong internal process should include:
Governance transforms compliance from a reactive function into an essential element of the compliance program. It allows retina administrators and physicians to anticipate payer behavior and adapt before disruption occurs.
As payer algorithms evolve, their “tolerance for ambiguity” shrinks. Practices that rely on context-free documentation will face denials that are harder to overturn and broader audits. Conversely, practices that continuously self-monitor, train, and document accurately will fare better financially and reputationally.
The message for 2026 is clear: precision protects. Every claim, every service, every note should demonstrate professional judgment, compliance awareness, and the patient’s medical need in full view.
Automation may review your claim, but your documentation must still speak to a human.
Modifier monitoring is tightening fast. Don’t wait for payers to define your risk profile. Visit Elizabeth Cifers Consulting or get in touch with Elizabeth to schedule a focused modifier and documentation review designed for retina practices navigating 2026 compliance expectations.
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