Inspecting a suspicious quantity of HCPCS codes

Behavioral Health is sadly typically targeted by bad actors as a chance for exploitation. The esoteric nature of behavioral companies might be susceptible to fraud, waste, and abuse (FWA) resulting from an absence of bodily signs. However investigating FWA in behavioral Health can boil right down to flagging suspicious billing patterns and due diligence. In a latest case, Cotiviti’s particular investigations unit (SIU) flagged suspicious exercise from a supplier exhibiting unusual billing patterns for HCPCS codes H2014 and T1017.

Suspicious billing: HCPCS H2014 and T1017

Healthcare Widespread Process Coding System (HCPCS) codes are used to report medical procedures, provides, and companies to Medicare, Medicaid, and different Health plans. A psychological Health supplier submitted claims with particular codes at the next frequency than friends. The submitted high-volume codes have been for:

  • HCPCS H2014, a code listed below Alcohol and Drug Abuse Therapy Companies/Rehabilitative Companies for quarter-hour of expertise coaching and improvement
  • HCPCS T1017, a code listed below State Medical Emergencies for quarter-hour of focused case administration

This supplier billed seven members for these codes solely, with the identical variety of items for every code for every member 100% of the time. The supplier additionally billed three hours for every member on every date of service.

Faulty place of service

Along with submitting a suspiciously excessive quantity of an identical claims, the supplier listed billing practices that mirrored not possible hours. The information confirmed that the supplier billed a number of dates of service for 2 sibling teams of two members, every group sharing a house greater than an hour away from the supplier’s workplace. The suppliers billed three hours of companies per day per member in each of those teams regardless of the space, spending six hours in every dwelling. Moreover, the supplier billed a number of consecutive days in a row that included spending six hours in a single dwelling after which spending three hours in one other dwelling situated 90 miles away. This may imply that the supplier claimed to have spent six hours in a single location after which allegedly drove hours away to spend three hours at one other dwelling. All of those irregular distances and companies proved problematic, and sure a case of not possible hours.

Cotiviti additionally decided that the supplier’s listed location was a residential dwelling, not an permitted location for people to go to obtain behavioral Health companies, making IT illegal for companies to be supplied at this location. The listed property proprietor of the residential homestead was neither the proprietor of the enterprise nor the rendering supplier. This Information was verified by means of the native county tax appraisal district.

An intensive investigation

Investigators reviewed claims knowledge for the supplier’s 18-month billing historical past, which recognized potential extreme companies. Peer comparisons recognized the supplier as an outlier amongst friends for the suspect process codes: The supplier acquired seven occasions extra fee for HCPCS T1017 and 21 occasions extra fee for HCPCS H2014 than the peer common.

On account of our knowledge evaluation, information have been requested for the seven members billed to find out if the companies had been supplied as billed and paid for. The entire funds in danger for the seven-member pattern reviewed is $78,000.

Irregular conduct

After Cotiviti reached out to the supplier for verification, numerous suspicious behaviors ensued:

  • The supplier didn’t reply to medical report requests.
  • The supplier’s web site is not energetic.
  • The supplier’s toll-free quantity is now disconnected, the native quantity is a mobile phone that goes straight to voicemail, and cellphone calls weren’t returned.
  • The proprietor is listed as a counselor; nevertheless, no license might be situated.

All sampled claims have been deemed not supported for failure to supply information and the case was referred to the state’s Workplace of Inspector Basic and lawyer normal. The plan additionally plans to conduct an on-site go to to confirm the supplier’s location and try to get hold of medical information.

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