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Detecting and preventing FWA in behavioral health claims

For the reason that COVID-19 pandemic started, telehealth has been a key think about treating behavioral well being points. In 2021, greater than 30% of surveyed adults reported signs of tension and despair, up from 11% in 2019. A part of assembly the demand for behavioral well being providers in the course of the pandemic included leaning more and more on telehealth providers, a key mechanism for delivering behavioral healthcare with out rising threat of publicity to COVID-19.

In actual fact, based on Cotiviti’s personal information, the quantity contribution for behavioral well being process codes in telehealth shifted from 0.53% in 2019 to 46.87% in 2021 (Determine 1).

Determine 1. Adjustments in workplace visits vs. telehealth from 2019 to 2021.

One other part of assembly the demand for behavioral well being providers was to vary regulatory necessities to permit simpler entry to telehealth. This included enjoyable restrictions on video protocols for elevated accessibility, in addition to flexibility in delivering behavioral well being providers throughout state traces, and different modifications.

However whereas all intentions have been to extend entry to care, this state of affairs of elevated demand for behavioral well being providers, reliance on telehealth, and elevated flexibility has created an ideal storm for unhealthy actors to leverage their schemes. These unhealthy actors have seen this case as a possibility for fraud, waste, and abuse (FWA).

Frequent, detected schemes embody:

Billing for particular person vs. group remedy

One scheme revolves round fraudulent reimbursement—billing plans for particular person remedy when they need to be billed for group remedy. Cotiviti’s personal information discovered a particular case the place 57% of 1 supplier’s encounters included billing for particular person psychotherapy visits for a number of members of the identical family. After a report evaluation, Cotiviti specialists confirmed that the 60-minute particular person remedy classes ought to have been billed as group remedy, leading to overpayments to this supplier totaling >$500K.

Unimaginable days

One other instance entails hours paid vs. dates of service. Cotiviti lately discovered one supplier to be coding over 96% of their claims as 60-minute psychotherapy—and in comparison with friends that share was a big outlier. When evaluation was carried out for dates of providers (DOS) vs. distinctive sufferers vs. the whole hours spent for every session, there was a big discrepancy: The supplier billed for 26 hours of service and eight sufferers per DOS on common, referred to as “unimaginable days,” and billed for greater than 24 hours for a complete of 122 separate DOS.

Inventive upcoding

A further FWA state of affairs in particular person psychotherapy contains “artistic upcoding.” Say {that a} supplier payments a 60-minute psychotherapy service with an added Analysis and Administration (E&M) code, which usually denotes an workplace go to. On this state of affairs, for the coding to be correct, the supplier would want to supply a “medical service” for the E&M code and a “psychotherapy service” for the PST code. However the probability of this mix occurring can be extremely uncommon.

Be taught extra about these sorts of schemes—and the way your group can defend itself—in our newest white paper, Rising telehealth: Catching FWA in behavioral well being claims. We discover FWA inside behavioral well being claims and the latest circumstances which have created alternatives for unhealthy actors.

Learn the white paper as we:

  • Study how and why weak factors exist inside behavioral healthcare declare funds
  • Stroll by FWA schemes associated to behavioral claims delivered through telehealth
  • Clarify how plans can each safeguard themselves and be assured in their very own declare accuracy

Read the white paper

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