Healthcare Fraud Shield’s Latest Article: Don’t Feel the Pressure of Wound Therapy Billing

Negative Pressure Wound Therapy (NPWT) is a technique used to aid healing of burns, acute and chronic wounds to include, without limitation, diabetic wounds, pressure wounds, surgical wounds and burns. In negative pressure wound therapy, the provider uses an electrical pump to apply controlled subatmospheric pressure through a sealed dressing, which creates a vacuum around the wound to remove fluids and infectious materials and to promote healing.

Considerations
There are many considerations that vary from payer to payer. Many payers will have specific medical policies governing when NPWT would be acceptable, what interventions should be attempted prior to NPWT and what requirements are necessary to support ongoing therapy.

In many cases, ongoing therapy will need to demonstrate that the therapy is efficacious. This typically requires that the treating provider perform or supervise dressing changes, and report on the wound size and characteristics.

How is it billed?
It is billed using HCPCS (Healthcare Common Procedure Coding System) Code E2402: Negative pressure wound therapy electrical pump, stationary or portable.This code covers the supply of an electric pump used to provide negative pressure wound therapy.

What to look for
One of the most common red flags concerns how long the patient is using NPWT. A patient that extends beyond four (4) months of NPWT, may be worth additional review. This will be especially true if the provider has a pattern of a disproportionately high number of patients being billed for atypically long periods (4+ months).

Some Behaviors and KPIs to Examine
1) Frequency: How long is the course of NPWT?
2) Density: What percentage of patients have atypically long durations of NPWT?
3) Connectivity: What other services and/or conditions does the patient have? Prior to NPWT? Concurrent with NPWT?

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.

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.

Healthcare Fraud Shield’s Latest Article: “What’s new in the CDT: Teledentistry?”

 

The American Dental Association develops and publishes the Current Dental Terminology (CDT) code set. According to the American Dental Association (ADA), “The purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately documenting dental treatment”.[i] As with the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT), CDT issues information with code changes including additions, deletions, and revisions.

In 2018, the ADA released the latest file with 18 new codes, 16 revised codes, and 3 deleted codes.[ii] Additionally, there were 4 errors noted in the CDT Errata.[iii] It is important to understand how changes to any code set could impact coding, reimbursement, and analytics.

Teledentistry
The ADA introduced the following two new codes around teledentistry. The ADA describes teledentistry as not being a specific service, but a broad variety of technologies and tactics to deliver virtual services.[iv]
D9995 Teledentistry – synchronous; real-time encounter
D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review
Both of these new codes are to be reported along with another procedure that was provided to the patient on the same date of service.

Synchronous vs. Asynchronous
The ADA describes the difference between synchronous and asynchronous as[v]:

Synchronous teledentistry (D9995) is delivery of patient care and education where there is live, two-way interaction between a person or persons (e.g., patient; dental, medical or health caregiver) at one physical location, and an overseeing supervising or consulting dentist or dental provider at another location. The communication is real-time and continuous between all participants who are working together as a group. Use of audiovisual telecommunications technology means that all involved persons are able to see what is happening and talk about it in a natural manner.

Asynchronous teledentistry (D9996) is different as there is no real-time, live, continuous interaction with anyone who is not at the same physical location as the patient. Also known as store-and-forward, asynchronous teledentistry involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to another practitioner for use at a later time.

The main difference between the two as noted above is the distinction between a service performed in real-time rather than information stored to be distributed at another time.

What to look for?
Since these are new codes it’s important to keep an eye on who is using the codes and why. As always, check to see if the codes are considered a covered service. If they are not included as a reimbursable service, look for any providers who submitted these codes and then resubmitted claims with different codes after receiving a denial.

[i] CDT
[ii] CDT Changes
[iii] CDT Errata
[iv, v] Teledentistry
For more information, or if you have any 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.

Search Smarter Not Harder!

The feeling of “information overload”is a real threat to investigators that rely on Internet searching for their information needs. When faced with literally millions of results from a single search engine, it is tempting to review only the first few hits and move on with or without the information you need. Chances are the mistake was made when the original search terms were too broad. This habit leaves the investigator with high quantity but
low quality information to choose from. In this article we will reveal instant ways to search smarter by utilizing Google’s Advanced Search techniques.

Shrink webpage results from millions to tens with the right terms!
The first step is to bookmark a link to the advanced search menu instead of the standard Google homepage. Now, take advantage of Google’s built-in logic and use the search bars to complete the command to the left OR execute the shortcut to the right. In the screenshot, typing words into the second box will tell Google to retrieve results for only the words “rat terrier”, in that exact order. This means all other results for rats or different breeds of terriers are not included. What does this mean for fraud investigators? Use this feature to search for specific people or business names while removing irrelevant results. Just think about how many businesses contain the word “health” alone – now you can be specific and search for the business “Sun and Moon Health Spa” without also getting “Sun and Moon Health Trail Mix”![1]

  

Search by excluding certain words
Perhaps you are researching an Iowan physician with a common name and a prominent person in California is clogging up your results. If you set up your search terms like the screenshot example, all of the results related to Mark Smith of California will be erased from the results and allow you to focus on Dr. Mark Smith of Iowa. What does this mean for fraud investigators? Start here to find exactly who you are looking for without always relying on subscription search tools. This can be especially helpful in locating news articles about or by the subject.

Search trustworthy website domains
Use site domains (.edu, .gov, .org, etc) to help narrow search results further and provide you with trustworthy information. If you’re looking for an academic resource, try narrowing results by”.edu”. If you’re looking for a press release from a government agency try narrowing results by “.gov”. What does this mean for fraud investigators? If you need to conduct research to determine if a procedure is considered experimental, try searching for it across one of the domains mentioned to locate evidence to help build your case. (Google Scholar is a bonus resource to help search for scholarly articles on a subject!) Additionally, you can also search for regulatory guidelines by focusing only on governmental results.

Refine your searches with shortcut
Google has created a reference for searching using shortcuts. Some highlights for investigators include:

Related searches: Find websites that link to a website address you already know. This could be helpful in finding additional outlets of the same practice with slightly different names or addresses that would otherwise not be obvious. You would type into the standard Google search bar an example such as, related:hcfraudshield.com

Using the cache- Searching the cache or copy of a webpage stored by Google is useful if you’ve noticed a sudden change in a website like the removal of a doctor’s name or removal of advertisement for free services. The cached view might enable you to capture a screenshot of the website before it was backed up by Google in order to help build your case. You would type into the standard Google search bar an example such as, cache:hcfraudshield.com

Scour the socials: A quick way to reveal all the places a username hides would be to search using the “@” symbol before the known username. This is helpful in revealing a practice’s YouTube channel, Facebook, or Instagram. These networks lead you to troves of comments from potential patients and associates. You would type into the standard Google search bar an example such as, @hcfraudshield

Initially, it might not feel natural to search using these advanced techniques, but with practice you will become a more productive searcher. If you have a favorite site or technique not covered here, feel free to share. If you need advice with Internet searching techniques you may contact us at SIU@hcfraudshield.com.

[1] All names are fictionalized for the purpose of this article; any similarities to names are coincidental

Healthcare Fraud Shield’s Latest Article: Facility Claims – So much data to analyze, so little time!

When analyzing claims data, most of the Fraud, Waste and Abuse (FWA) community would likely agree that it is easier to review professional claims data versus facility data.  Facility data can present many obstacles and also contains a variety of fields that are often overlooked in analysis. 

 

Let’s start with the obstacles:

• Payment for out of network vs in network facilities can vary
• Payment guidelines for facilities can vary within a payer
• Payment guidelines for facilities can vary from state to state
• Complicated contracts for in network facilities

Some facilities get paid by the Diagnosis Related Group (DRG), some by percent of charges, some by per diems, and then other plan specific contracts.  This variety can lead to confusion among investigators, analysts, auditors as well as the facilities.

Data elements:

 

It is typical to include in analysis common fields such as DRG, Admitting Diagnosis, Primary Diagnosis, and Revenue Codes.     There are several other fields that are often overlooked such as Type of Bill, Condition Codes, Present on Admission, Admission Date, Discharge Date and so much more. 

What is Type of Bill and why is it important?

 

According to CMS, Type of Bill is a “four-digit alphanumeric code [that] gives three specific pieces of information after a leading zero…. The second digit identifies the type of facility. The third classifies the type of care. The fourth indicates the sequence of this bill in this particular episode of care. It is referred to as a ‘frequency’ code”. [1]  For example, a Type of Bill that starts with the number 1 (ignoring the leading zero), represents that the type of facility is a hospital as opposed to a clinic, skilled nursing facility and more.  The next digit typically provides information as to whether or not the member is inpatient, outpatient or can be used for Clinics (although there are handful of other identifiers).  Finally, the last digit provides a several values relating to admissions, type of claim and more.

One example of the importance of using Type of Bill in analysis is to determine when patients are admitted, review the rate of admissions and to review readmissions.  Many facility contracts contain clauses that prohibit reimbursement for readmissions within a certain timeframe from a discharge if the readmission is for the same type of episode.    It is important to become familiar with not only the structure of this field (as well as the other fields noted above) and the values, but also your respective organizations process for payment to these facilities. 

 

Using a tool such as PostShieldTM can help simplify some of the analysis surrounding Facility Claims.  For more information or if  you have any questions or comments, please contact us at SIU@hcfraudshield.com.

 

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[1] CMS

Quick Hits for Identifying Pharmacy and Medical Schemes on May 23rd, 2017 at 2:00 PM EST

Speakers:

Kenneth Cole, III, AHFI, CFE, CPC

Maria Seedorff, DC, AHFI, CPC

Kathleen Shaker, RN, BSN, CPC, CPC-H, AHFI

Karen Weintraub, MA, CPC-P, CPMA, AHFI

Click HERE to register!

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

Healthcare Fraud Shield’s Latest Article: Get Ready for Big Coding Changes in 2017

The new year will ring in over 140 new CPT codes and many other revisions to existing codes. We will bring you a 2-part series of new codes to watch in 2017 that could be misused leading to fraud, waste and abuse (FWA).

Today’s article will highlight new codes in the Medicine section. Listed below are several of the new codes and potential areas of risk for FWA:

96160- Administration of patient-focused health risk assessment instrument (e.g. health hazard appraisal) with scoring and documentation, per standardized instrument). This code replaces 99420 (administration and interpretation of health risk assessment instrument. Unlike the 99420, this new code must include “scoring and documentation, per standardized instrument,” so this part of the service cannot be reported separately. CPT guidelines also state that these codes cannot be reported with 99408 or 99409 (alcohol/substance abuse screening).

96161- Similar to 96160, this code is used for the administration of caregiver-focused health risk assessment instrument (e.g. depression inventory) and must contain scoring and documentation. It also cannot be reported with 99408 or 99409.

Three new codes (97161, 97162, 97163) are being introduced to replace 97001 (Physical therapy evaluation). These new codes add specificity and details regarding the scope of the evaluation and level of decision making. For instance, CPT 97163 is a high complexity evaluation requiring, 3 or more personal factors and/or comorbidities that impact care; an examination of body systems addressing 4 or more elements; a clinical presentation with unstable and unpredictable characteristics and clinical decision making of high complexity. The evaluation typically takes approximately 45 minutes face-to-face with the patient and/or family. 

Because these codes are so new to the physical therapy profession, there is the potential for upcoding, billing errors and misuse. As the year progresses, it would be prudent to identify the outliers consistently billing the highest level evaluation (97163). The American Physical Therapy Association has a wealth of educational materials on their Website regarding proper use of the codes. Here is a link to their coding Quick Guide.

The Occupational therapy evaluation code (97003) is similarly being replaced with 3 new codes (97165, 97166, 97167) for low to high complexity evaluations, and the Athletic Training evaluation code (97005) is being replaced by 97169, 97170 and 97171. Check out the American Occupational Therapy Association’s website for educational materials such as this comprehensive document and and the National Athletic Trainers’ Association’s Website and billing guide.

These new physical medicine codes will be ones to keep on the radar in 2017! 

Join us for Healthcare Fraud Shield’s next Webinar: 

Get Ready for Big Changes in 2017 on January 24th, 2017 at 2:00 PM EST

Speakers:

Kenneth Cole, III, AHFI, CFE, CPC

Kathleen Shaker, RN, BSN, CPC, CPC-H, AHFI

Karen Weintraub, MA, CPC-P, CPMA, AHFI

Click HERE to register!

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

Reviewing Modifier -91, Reviewing Modifier -91, Reviewing Modifier -91

No, it’s not a typo! The title of the article is in triplicate to emphasize the definition of Modifier -91, which according to the AMA is “Repeat clinical diagnostic laboratory test.”  The long description noted in Appendix A of the AMA CPT¹ book states: 

 

In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.  Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91.  Note: This modifier may not be used when tests are rerun to confirm the initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required.  This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing).  This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

How does Modifier -91 differ from Modifier -59

 

Modifier -59, which is used for separate and distinct procedures, can also be appended to laboratory tests.  With laboratory tests, modifier -59 is used is to identify when a test is performed more than once, but on different specimens.  Whereas, Modifier -91 is when the test is being repeated on the same specimen.

 

 What to look for?

• Look for a provider billing modifier -91 when the test describes a series of test results such as CPT 82951 which is a tolerance test (GTT), 3 specimens (includes glucose).  If the provider obtained anywhere from 1-3 specimens, then CPT 82951 should be billed once with one unit.²  
• Any provider excessively billing for modifier -91.  What percentage of their claims show modifier -91? 
• Are the claims the result of resubmissions? Do you see prior claims denied and then resubmitted with modifier -91?
• Modifier -91 can only be used with laboratory codes.  Is modifier -91 being appended to codes that are not laboratory codes?
• Are providers submitting multiple tests under different IDs to avoid using modifier -91?  Providers may try this tactic in order to avoid suspicion if in appropriate billing.

As a reminder, every payer has different clinical as well as reimbursement policies.  Some payers request that repeated tests be billed on one claim line with modifier -91 and the appropriate number of units.  Other payers want to see each repeated test on their own individual claim line with modifier -91 appended to the second and subsequent claim lines. Refer to your respective organizations to determine what is appropriate for your company.

If you have a question or comment or are interested in learning more about how Healthcare Fraud Shield can help you data mine for modifier -91, contact our subject matter experts at SIU@hcfraudshield.com.

REFERENCES

1) AMA CPT 2016 Professional Edition, Appendix A

2) AAPC

Join us for Healthcare Fraud Shield’s NEXT COMPLIMENTARY WEBINAR titled  “Modifiers: Changing the Game” on Tuesday, October 4th, 2016  at 2:00 pm EST. Click HERE to register and for information regarding eligibility. 

Healthcare Fraud Shield’s Latest Article: Are You Off the Mark with Off-Label Drugs?

Are You Off the Mark with Off-Label Drugs

The United States Food and Drug Administration (FDA) is responsible for regulating pharmaceuticals.  FDA oversight includes, but is not limited to the approval of pharmaceuticals to be sold and marketed and the indications for the use of those medications.  Indications may relate to the age of the individual the drugs are being prescribed to, the dosage amounts, administration method, or the illness or symptoms for which the drugs are intended to treat.

Prescribing medications outside of the original intention is called “off-label use.” Physicians are not legally prohibited from prescribing medications off-label; however, the manufacturing companies are prohibited from marketing drugs for off label use.  Additionally, many insurance companies maintain policies prohibiting the coverage of off-label use leaving the beneficiaries financially liable for purchasing any of those medications.

Off-Label Use in the News

On October 10, 2008, the United States accepted a guilty plea from Cephalon, Inc (recently acquired by Teva Pharmaceutical Industries LTD) for “distribution of misbranded drugs; inadequate directions of use.”[1] As part of this judgment Cepahlon agreed to pay $425 million dollars which included both civil and criminal settlements.  The settlement was related to the misbranding of 3 drugs:  Actiq, Gavitril, and Provigil.  Actiq is approved for opioid-tolerant cancer patients; however, it was being promoted as Cephalon for non-opioid tolerant cancer patients and for chronic pain.   Gabitril, an anti-epilepsy drug was marketed for anxiety, insomnia and pain.  Provigil, approved to treat sleepiness associated with narcolepsy, sleep apnea and shift work disorder was promoted to treat general symptoms of sleepiness, tiredness, decreased activity, lack of energy and fatigue. [2]

What are the Risks of Off-Label Use?

There may be financial risks as well as potential dangers to patient safety.  Physicians may open themselves up to potential lawsuits.   Off-label use can also lead to unexpected and even life-threatening side effects.

What Should Investigators Know?

1. Be familiar with your respective plan policies regarding what medications, if any, are covered for off-label use.
2. Data mine for drugs commonly prescribed for off-label use, particular those being used to treat pain.  Common schemes involve diversion, kickbacks between prescribers and pharmacy, and kickbacks between prescribers and members.
3. Know how to identify the various drugs in your claims and/or fraud detection systems.
4. Use your anti-fraud software to crosscheck members’ pharmacy claims to their medical history (if both types of data are available) to determine if the prescriptions seem appropriate.  You may need to bring a Medical Director or Nurse Reviewer to verify the relevance of the medications.

If you have any questions or comments, please feel free to email us at info@hcfraudshield.com.

References

[1] Cephalon Judgment

[2] US Dept. of Justice