Billing Codes: The Golden Gateway to Fraud

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The use of telemedicine has grown rapidly since the pandemic began. In the troubled times of COVID-19, telemedicine offers patients and providers a safe alternative to onsite medical treatments and diagnosis.

In August 2020, we already discussed the immense increase in telemedicine treatments in the U.S. on #FraudFactFriday and the positive healthcare benefits telemedicine offers.

Two trends that were already emerging at this point are proving to become true:

* Telemedicine will remain a permanent and mainstream fixture in healthcare long after the U.S. emerges from its pandemic lockdown, and

* Fraudsters take advantage of emerging opportunities to gain profit out of telemedicine.

Expect Wide Range of Coding Scams

Telemedicine fraud ranges from small amounts to million-dollar scams. It may go from massive multinational operations to smaller schemes by individual medical providers or groups of providers colluding to exploit telemedicine codes jointly. Abuse of telemed billing codes is the fraudster’s golden gateway to stealing insurance money. While health insurers have rapidly expanded telemed fraud training, many automobile and workers’ compensation insurers must accelerate their anti-fraud learning curves and training.

Fraudsters are rapidly gaining telemed coding skill sets and knowledge themselves. Insurers must gain the upper hand now by knowing telemedicine codes and coding fraud tactics better than the scammers.

Cracking Telemedicine Codes: Deciphering the Signals of Fraud

Based on our nearly 50 years of combined coding experience and expertise from our daily coding analysis work for insurance companies, Tami Rockholt and I wrote a detailed article for the Journal of Insurance Fraud in America (JIFA) by Coalition Against Insurance Fraud to help insurers:

* develop an understanding of the changes telemedicine guidelines and codes undergo

* fully understand telemed codes

* develop a vigilant eye for fraud.

We know the telemedicine and traditional CPT medical codes intimately. We expose thousands of suspect medical bills for insurers across all lines every year. We also give seminars on medical billing and coding issues (including telehealth training), and testify as coding experts at insurance-fraud trials. This paper provides you with some detailed insights we have gained over the years.

Anti-Fraud Action Steps

Insurers can stay ahead of oncoming telemedicine fraud by taking common-sense action steps:

• Stay current with telemedicine training. Make sure your claim handlers, investigators, and vendors can fully recognize suspicious telehealth charges.

• Look for new medical providers and check their licenses and credentials. Do an online search to see if the provider is soliciting new patients.

• Carefully screen high-level evaluation and management codes (ending in 4 or 5) performed in a telehealth setting. These high-level codes are most often used while examining patients with complex or high-risk injury or disease. They are difficult to perform in a telemedicine encounter.

• Watch for misrepresenting of virtual services. Make sure charges for real-time video interactions are not billed for exams performed by telephone.

• Scrutinize new-patient visits for new or unusual diagnoses that don’t fit the claim. Also, watch for suddenly increased frequency of services.

• Keep current on the temporary rules and waivers and watch for changes in allowable telehealth codes.

Conclusion

With the rapid expansion of telemedicine due to the pandemic, the bad news is that the fraudsters are rushing to take advantage of the opportunity.

The good news is, insurers can stay ahead of the game and protect their premium payers by intensively training their front-line troops to recognize and evaluate telemedicine claims for potential fraud. Intelligent software solutions can automatically screen telemed bills for irregularities and the patterns mentioned above, helping insurers to head off trouble.

 



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About the author

  • Michael Fossey is a partner at Rockholt and Associates, and together with Tami Rockholt, is active in the fight against insurance fraud. Michael works as a consultant and subject matter expert for INFORM Software Corporation. Using his background in engineering, Michael is the author of INFORM’s algorithms to automatically detect medical billing fraud in the RiskShield platform.

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