Evaluation confirms >$1 million in improper claims

Health plan investigators rely closely on ideas from members, however these ideas require a barrage of analytics and strategies carried out by material specialists with scientific information to confirm them. Whereas anomalies occur, IT‘s necessary to again up findings with proof, or to discover a bigger sample that might present clues about intent.

Let’s take a look at a latest case the place a Cotiviti consumer bought a tip that resulted within the identification of greater than $1 million in improper claims.

Verifying a tip with the SIU

A consumer acquired a tip from an inside division and forwarded IT to Cotiviti’s particular investigations unit (SIU) for additional knowledge evaluation. The tip alleged that the supplier was billing for companies not rendered and was failing to reassess members’ wants. The consumer acquired extra Information that the mother or father of the members from the preliminary tip was being paid by the supplier for advertising companies.

Cotiviti’s preliminary knowledge evaluation confirmed that this supplier was billing extreme quantities and claims per affected person. The supplier billed for a number of members per family with out acceptable modifiers and billed companies for members who didn’t require dwelling Health companies. Cotiviti reviewed medical data and located companies billed below HCPCS codes:

• S9123 – Nursing care, within the dwelling; by registered nurse (RN), per hour
• S9124 – Nursing care, within the dwelling; by licensed sensible nurse (LPN), per hour
• S9215 – Respite care, within the dwelling, per diem
• T1019 – Private care companies, per quarter-hour, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, a part of the individualized plan of remedy (this code will not be used to establish companies offered by dwelling Health aide or licensed nurse assistant)
• T1002 – RN companies, as much as quarter-hour
• T1003 – LPN/licensed vocational nurse companies, as much as quarter-hour
• T1005 – Respite care companies, as much as quarter-hour
• T1013 – Signal language or oral interpretive companies, per quarter-hour
• T1031 – Nursing care, within the dwelling, by licensed sensible nurse, per diem
• G0494 – Expert companies of an LPN for the remark and evaluation of the affected person’s situation, every quarter-hour (the change within the affected person’s situation requires expert nursing personnel to establish and consider the affected person’s want for doable modification of remedy within the dwelling Health or hospice setting)

This medical assessment substantiated the allegation and recognized a 100% error fee.

Quantifying the FWA

Upon receiving the preliminary tip, Cotiviti’s investigators analyzed knowledge for suspect billing patterns. They reviewed the final three years {of professional} claims knowledge and recognized a number of members of the identical family receiving companies on the identical date of service with out the correct modifiers.

Evaluation additionally recognized analysis code utilization below code J449 (unspecified persistent obstructive pulmonary illness) in step with the allegation that the supplier was billing companies for members who didn’t require dwelling Health companies and didn’t have supporting documentation for IT.

The at-risk {dollars} related to Cotiviti’s preliminary assessment of those companies was estimated at greater than $1.3 million.

Searching for justice

Following our investigation, Cotiviti confidently referred the supplier to the consumer’s personal SIU for investigation of potential fraud after conducting two ranges of inside assessment, which recognized a 100% error fee based mostly on a number of documentation points together with the next:

• A number of data had lacking required documentation resembling preliminary evaluation, plan of care, and progress notes to assist that the affected person required non-public responsibility nursing
• The variety of models billed didn’t match the variety of hours documented in data and no time stamps to find out begin and cease time of protection
• Duplicate declare strains had been submitted by the supplier

Cotiviti additionally cooperated with regulation enforcement to supply background on steps taken within the audit, assessment outcomes, and present standing. Our investigators labored with the consumer to help the regulation enforcement investigation, supporting compliance with subpoenas and requests for Information.

Because of the legal investigation, the supplier has agreed to pay $3 million for allegations of violating the False Claims Act. The general recognized overpayment was upheld from the audit and totaled almost the identical quantity recognized by Cotiviti’s preliminary assessment. In January 2024, 9 people had been indicted for expenses of healthcare fraud conspiracy, cash laundering, and obstruction of justice.