Spotting red flags in adult day care claims

Grownup day care applications present very important look after seniors and different susceptible adults, providing them each bodily and psychological stimulation whereas additionally offering respite for his or her caregivers. So, when Cotiviti’s fraud, waste, and abuse (FWA) crew observed a number of purple flags in a single clinic’s claims for these companies, we initiated an investigation—finally resulting in the invention of an overpayment of roughly $1 million.

On this third installment of our Cotiviti FWA Insights weblog sequence, our particular investigations unit (SIU) will stroll by a current case of inappropriate billing for these grownup day care companies.

What’s grownup day care?

As famous by AARP, whereas group senior facilities are usually a useful resource for more healthy seniors, grownup day care facilities “serve these with bodily or cognitive disabilities who may have extra supervision and companies,” with greater than half of tourists having some type of cognitive impairment. Greater than 4,000 such facilities function all through america. A small variety of suppliers of such companies sadly have been identified to attempt to improperly improve their reimbursement, usually focusing on Medicare or Medicaid applications, as proven in these examples:

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  • The proprietor of assorted facilities in Texas was convicted of healthcare fraud for billing for objects or companies that weren’t truly supplied to purchasers of the facilities
  • Two grownup day care facilities in Massachusetts paid greater than $1 million to resolve allegations of improperly billing the state’s Medicaid program for companies that weren’t supplied or exceeded permissible billing practices
  • The proprietor of two facilities in Michigan was convicted of healthcare fraud for billing Medicare for psychotherapy that was not supplied

The audit: Telemedicine modifier raises a purple flag

The clinic in our instance billed Cotiviti’s shopper, which serves a big Medicaid inhabitants, utilizing HCPCS code S5102 for grownup day care companies. Whereas performing information evaluation and peer comparability, a Cotiviti investigator recognized the clinic as a serious outlier in billing quantity for this code. As well as, the clinic had appended greater than 1,000 distinctive affected person encounters with modifier GT, indicating that the companies had been supplied by video and audio telecommunications programs (in different phrases, by telemedicine), which is usually ineligible for cost with HCPCS code S5102.

On prime of this, the clinic’s billing patterns indicated potential unbundling of analysis and administration companies and preventive visits by appending modifier 25, which may be abused to bypass declare enhancing programs and obtain increased reimbursement.

Extra purple flags included:

  • The clinic failed to supply medical data for almost 1 / 4 of the 150 declare traces our SIU sampled
  • The medical data our crew reviewed didn’t comprise a referral from a major care supplier or different forms of documentation that will exhibit their appropriateness
  • No chief grievance was documented to assist the billing of Analysis and Administration (E&M) companies

To prime this all off, our SIU carried out analysis on laws surrounding grownup day care companies within the clinic’s metropolis, which revealed an govt order was issued through the COVID-19 pandemic that grownup day care facilities be closed and suspended. The manager order was in place whereas the clinic continued to invoice in-person and telemedicine grownup day care companies.

The upshot: A $1 million overpayment is recognized

Cotiviti really helpful denial of the claims, which the supplier appealed. The well being plan is pursuing an overpayment of almost $1 million, which is able to finally assist the shopper ship higher look after susceptible Medicaid populations.

To find or maybe even forestall such schemes sooner or later, well being plans ought to take into account the next approaches:

  • Carry out intensive evaluate of each inner and state documentation and billing pointers for grownup day care companies
  • Evaluate suppliers and clinics to their friends to find out outlier billing patterns
  • Decide whether or not modifiers had been applicable for the companies billed, paying explicit consideration for modifier 25 for unbundling of E&M companies

Whether or not you’re on the lookout for assist or a complete outsourced crew, Cotiviti’s SIU might help your plan to catch FWA in its tracks. Cotiviti’s FWA options present an end-to-end course of for flagging, investigating, and stopping FWA inside claims. Our FWA Validation is a prepay resolution that catches suspect patterns early, maximizing returns by stopping misguided or wasteful claims cost. And FWA Administration covers the newest in fraud detection and compliance for a sturdy resolution that retains your group present and safeguarded in opposition to the newest schemes. Learn our reality sheets to study extra.

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