Healthcare Fraud Shield’s Latest Article: Controlling the Uncontrollable?

Do you ever use Fitbit’s Relax feature which provides guided breathing sessions? While in this mode, the user can concentrate on clearing his/her mind, lowering the heart rate and as the feature suggests, just relaxing.     Certain bodily functions such as your heart rate, blood pressure, skin temperature are controlled involuntarily by our nervous system.   Using the Fitbit or other similar devices to help control some of these areas is akin to what we know in the medical field as biofeedback.   According to WebMD¹:

 

The idea behind biofeedback is that, by harnessing the power of your mind and becoming aware of what’s going on inside your body, you can gain more control over your health.

 

How is Biofeedback performed?

Although methods vary slightly, typically a biofeedback therapist will attach electrodes or sensors to the skin to monitor things such as blood pressure, heart rate, skin temperature, peripheral vasomotor activity and more. The therapist utilizes a variety of techniques such as deep breathing, progressive muscle relaxation, guided imagery and mindful medication.²

 

Why is Biofeedback performed?

A variety of conditions may warrant utilizing biofeedback including, but not limited to:

• Constipation
• Incontinence
• Migraines
• Neuromuscular rehabilitation for patients who had a stroke

How is it billed?

These are the codes that can currently be used:

• E0746 – Electromyography (EMG), biofeedback device
• 90901 – Biofeedback training by any modality
• 90911 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry

CPT 90911 will be deleted effective 12/31/2019 and replaced with two codes:

• 90912- Biofeedback Training, Perineal Muscles, Anorectal Or Urethral Sphincter, Including Emg And/Or Manometry, When Performed; Initial 15 Minutes Of One-On-One Physician Or Other Qualified Health Care Professional Contact With The Patient
• +90913 – Biofeedback Training, Perineal Muscles, Anorectal Or Urethral Sphincter, Including Emg And/Or Manometry, When Performed; Each Additional 15 Minutes Of One-On-One Physician Or Other Qualified Health Care Professional

Is Biofeedback a covered service?

Typically, biofeedback is covered by health insurance when performed by a licensed provider for a limited number of conditions such as:

• Chronic constipation
• Fecal incontinence
• Stress urinary urgency
• Migraine and tension headaches
• Muscular re-education after a stroke

It is considered experimental, investigational and unproven for conditions such as:

• Autism
• ADHD
• Spasmodic torticollis
• Epilepsy, etc.³

What to look for?

• Inappropriate medical diagnoses to support the service
• Excessive time submitted for the new add-on code
• Providers hiding these services under other codes when performing them for the for conditions that are considered investigational.⁴

If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

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[1,2] Biofeedback

[3]   Medical Policy

[4]   List of Providers

Healthcare Fraud Shield’s Latest Article: Developing a Method to Uncover Abnormal Billing Behavior

As with past articles from Healthcare Fraud Shield, future articles will focus on specific schemes to look for, where we will examine specific schemes or issues supported by precise codes, be they procedures, diagnoses, modifiers, or DRGs (Diagnosis Related Groups) associated with high risk behaviors.

However, in this article, we want to take a step back and discuss methodologies to analyze data, so that any behavior, known, or not, will raise to the surface, and predicate additional review.  In many future articles, we will relate many of these concepts to methods to uncover the specific schemes discussed.

Developing a Methodology

One of the best ways to uncover “outliers” is to first understand the areas of risk. Think about your successful cases, or recent cases in the news. What common threads did they have? Once you isolate on these “macro” level behaviors, you can begin to look for them, wherever they may hide.

You should develop a method that accounts for the major behaviors you identified. Going through your cases like a checklist is one way to begin to formulate your behavior list. Keep in mind the behavior list is not the list of allegations, it is more the why behind it. For example, what is upcoding? Billing for a higher level of service than what was provided. How/why does that happen? Many factors can impact the degree to which a service is potentially up codded. Some of these include, specialty, condition, and even geography. Your method should answer the why and the how.

One approach you may consider is the below Suspect Behavior Profile When you examine your cases, you will probably find that many of those cases exhibited one or more of the following behaviors driving the scheme. This is just one approach, feel free to use this as a springboard, add to it, subtract from it, make it work for you.

Frequency

Something is happening too frequently. Most commonly, it could be repeat visits, but it can be more hidden, such as suspicious duplication of procedures over time.

Density

Density looks at how clustered or concentrated behaviors are. For example, a very simple density issue is too many patients in a day. However, as another example, it could look at things such as abnormal numbers of patients from a specific employer group.

Intensity

Intensity is analogous to the upcoding mentioned above. On the simple side, it can be procedural upcoding, billing a higher level of service within a group of related procedures. It can also include examples that include a modifier, or diagnosis that is added to a claim (think DRG) that increases the payment.

Velocity

Velocity measures the degree to which a behavior is increasing or decreasing. “Spike” detection often considers only positive changes, but abnormal negative changes can be just as enlightening. Change detection methodology is important to uncover spikes and dips within payments, patient volume and services.

Connectivity

The last of the five (5) behaviors in the profile is connectivity. This looks at relationships between attributes. For example, we often hear of “link analysis” which identifies relationships between provider and patients. However, in addition, and often overlooked, there are “connections” between many other attributes. Examples could include procedure to procedure, procedure to gender, procedure to specialty, etc.  

Take Away

• Dissect some of your prior cases and think about the behaviors that manifested as potential suspicious behaviors you would like to detect in a more strategic approach
• Develop specific KPIs for each of those behaviors. Some examples include:
  • Frequency: Visits/Patient
  • Density: % of Patients
  • Intensity: Average Level of Service
  • Velocity: % Increase
  • Connectivity: % of Total
• Look for outliers at the provider, procedure and diagnosis level for those KPIs. That could be indication of issues that require additional review
• Conduct additional review, and validate/refine the KPIs that are working best

If you have questions specific to this article, you may contact Jim McCall at jmccall@hcfraudshield.com.

If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.

If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.