Flagging suspicious exercise associated to COVID-19 testing

The early days of the COVID-19 pandemic introduced a number of latest challenges for correct coding and billing. Throughout this time, fast adjustments led to many harmless errors, but additionally created a gap for unhealthy actors trying to exploit the pandemic for their very own revenue. Amongst them, COVID-19 drive-through assessments, a life-saving measure for diagnosing and advising the general public, was too usually used as a nefarious device for revenue. Whereas any such testing is not prevalent in the present day, many Health plans have look-back durations stretching way back to three years, and particular investigations items (SIUs) proceed to analyze knowledge associated to such potential schemes.

On this weblog, we’ll discover how one supplier was flagged earlier in 2023 for potential fraud, waste, and abuse (FWA) exercise associated to COVID-19 drive-through assessments.

Flagging suspicious exercise

Throughout the declare enhancing knowledge evaluation course of, a supplier was flagged for extreme high-level analysis and administration (E&M) providers at COVID-19 drive-through testing websites, in addition to inappropriate locations of service (POS) utilization and “inconceivable days.”

Since E&M providers are thought-about cognitive and never procedural, taking a COVID-19 take a look at is a transparent mismatch for the codes submitted. Among the many suspicious POS codes, the supplier billed POS 11, an workplace code, for COVID-19 drive-through providers and POS 15, a cell website code, for E&M providers. As for the inconceivable days—a state of affairs through which extra providers are billed than is feasible for the given period of time—the supplier billed over 30 dates of service for 50 or extra sufferers using high-level E&M codes.

Digging deeper

A Cotiviti investigator reviewed claims knowledge for the supplier’s 24-month billing historical past, which revealed potential extreme billing and inappropriate providers. The claims knowledge recognized one supplier that billed 60% of claims for high-level providers. The supplier was flagged as an egregious outlier when it comes to extreme high-level providers billed for COVID-19 drive-through testing websites in addition to using POS 15 with E&M providers.

The investigator carried out analysis surrounding COVID-19 testing drive-through websites and recognized that based on AAPC, CPT 99211 must be utilized for COVID-19 symptom and publicity evaluation and specimen assortment offered by scientific workers to the supervising doctor or nonphysician practitioner’s (NPP) providers. The investigator additionally researched the supplier’s web site, which marketed fast COVID-19 testing to sufferers from their automobile.

Assessing the injury

Cotiviti’s medical assessment group accomplished an preliminary medical file assessment on 46 sampled declare traces and recognized an general error fee of 100% attributable to inadequate and/or lacking documentation, flagging the next points:

• Documentation didn’t assist the extent of E&M providers billed
• Documentation didn’t embrace take a look at outcomes to assist the COVID assessments carried out
• Documentation didn’t assist the POS utilized
• Documentation indicated the potential cloning of data

The extrapolated overpayment for the preliminary assessment totaled greater than $1.4 million.

Whereas COVID-19 drive-through testing is not as prevalent, COVID-related claims proceed to contribute to ongoing circumstances of FWA. As demonstrated by this investigation, staying vigilant towards suspicious exercise by utilizing methods that may assist flag outliers early may also help forestall overpayments or flag them as shortly as potential, rising the probability of restoration.