2 Health Insurance Fraud and Abuse The National Health Care Anti-Fraud Association estimates at least $68 billion dollars is lost to fraud and abuse each year—just in the private sector.Medicare and Medicaid lose an estimated $60 billion or more annually to fraud, including $2.5 billion in South Florida.1 out of 10 physicians has reported medical signs or symptoms a patient didn’t have in order to help a patient get services paid for.1 out of 5 U.S. adults say it’s acceptable to defraud insurance companies under certain circumstances.80 percent of healthcare fraud is by medical providers, 10 percent is by consumers and the balance is by other sources
3 Most Common Types of Fraud and Abuse Billing for services, procedures, and/or supplies not provided.Misrepresentation of what was provided, when it was provided, the condition or diagnosis, the charges involved, and/or the identity of the patient.Providing unnecessary services or ordering unnecessary tests solely to generate revenue.Unbundling of procedures.Double billing.Upcoding.Kickbacks.Artificially inflating prices.
4 The Argus SolutionReviewing claims to determine the coding is correct per Medicare and AMA guidelines.Verifying that the physician(s) billing for the services are the ones who actually performed them.Verifying that the charges billed are accurate and not specific plan exclusions.Reviewing hospital bills line by line for billing errors, duplicate charges, coding errors, inconsistencies in pricing, upcoding, unbundled charges, and other spurious practices.Requesting medical records and conducting peer independent reviews on treatment that appears to be not medically necessary.Negotiating prompt pay discounts on out of network claims.
5 Argus Areas of FocusCoding: Facilities and providers improperly unbundling or upcoding charges, or not appending the appropriate modifiers per Medicare and AMA guidelines.Pain Management: Medical necessity reviews on all types of injections provided in the lumbar, thoracic, and cervical regions. For just one types of these injections, OIG found that 63% of Medicare payments for facet joint injections in 2006 did not meet program requirements, causing $96 million in improper payments that year. Medicare paid another $33 million in improper payments to facilities for the treatment. Medicare claims for facet joint injections rose by 76% between 2003 and 2006, which triggered OIG and CMS scrutiny.
6 Argus Areas of Focus (cont) Inflated/erroneous hospital charges. A percentage discount off a hospital bill filled with billing errors, unbundled charges, inflated charges, etc., defeats the purpose of the discount to begin with.Electrodiagnostic (EDX) testing: A test that has been rife with fraud and abuse since the early 2000’s and is done many times to solely generate revenue for the physician/facility. Claims are reviewed per the guidelines of the American Association of Neuromusuclar and Electrodiagnostic Medicine (AANEM).Therapies: Chiropractic treatment is a highly abusive area of treatment. Medical necessity reviews are conducted to determine if treatment is truly medically necessary or maintenance in nature.Upcoded Evaluation/Managements: Billing for a higher level of office visit than was performed. Dr. Hotchandani recently was convicted of this for defrauding BC/BS of nearly $800,000.
7 Argus Areas of Focus (cont) Experimental Treatment.Abusive providers/facilities: Some are more prone than others to questionable billing practices/behavior. These provider’s TINs are flagged and each claim is reviewed before processing.Anything and everything that looks questionable.
8 Case Study #1A VA hospital submitted an out of network outpatient bill for the technical component of myocardial perfusion imaging. The costs of the tests were $4,993.63; however, they were billing $11, for the contrast used.The National Drug Code (NDC) number was requested for the contrast so that we could run the Average Wholesale Price (AWP) for it. For out of network claims, we reimburse the AWP + 10%.The facility refused to submit the NDC number, stating that they “knew we were going to cut it down”. Even after explaining to them that their reimbursement rate would be higher if they provided us with the specific NDC, they still refused to do so.Based on the information submitted, a comparable AWP was found for the contrast. Total amount allowed was $ The facility has yet to appeal, nor have we heard from the patient that they are attempting to balance bill him for this amount.This is a common tactic; to try to bill something outrageous to see if the carrier pays for it. If they do, great, if not, they write the charges off.
9 Case Study #2An out of network claim was submitted for the professional (physician) component of a major back surgery, along with assistant surgeon charges and intraoperative monitoring. The total cost of the billed charges was $201,The claim was sent to a peer independent reviewer for a thorough review to determine that all the services were documented as billed and were coded properly per Medicare and AMA coding guidelines.The review found that 6 of the procedures billed for were not documented in the operative report. An assistant surgeon was not medically necessary for 2 of the procedures. 4 of the procedures were unbundled. The intraoperative monitoring physician unbundled 2 of his charges.Total savings on the file: $51,
10 Case Study #3Physician billed three outpatient surgical procedures for a total of $14,However, physician did not append the appropriate modifier (51) to the secondary procedures as required per Medicare/AMA guidelines.Secondary procedures were manually reduced by 50% of the PPO fee schedule amount.Total savings: $3,This is one of the more common coding issues out there.
11 Case Study #4Patient saw a pain management physician for a new evaluation, who then proceeded to do a set of facet joint injections. Total billed: $7, for one date of service in an office setting.Medical records were requested and the file was sent to a peer independent reviewer of the same specialty for review.Reviewer stated that facet joint injections were not an accepted standard of care for the patient’s condition based on the submtted medical record.Total savings for one date of service: $6,581.40
12 Case Study #5Patient was inpatient at a facility for 57 days. Total billed charges: $224,The PPO discount present on the claim was 30% of billed charges, for a total allowed amount of $156,Itemization was sent to a vendor for a line by line review. The vendor found $20, in unbundled charges and billing errors.The total billed amount was reduced by this amount, and the 30% PPO discount then applied for a new allowed amount of $142,Total savings: $14,