It does not matter how many times we uncover healthcare claim schemes, the things Claritev’s Payment Integrity team finds in healthcare claim data leave us shaking our heads. We’ve compiled another round of intriguing patterns—and subsequent law enforcement impact—our team identified as they dug into healthcare claim data. While we try to present the findings in a humorous way, we’re well aware of how serious they are for both their potential impact on patients as well as healthcare payors.
It didn’t take a brain surgeon to determine something was off.
We received numerous claims from doctors using a “brain health” device named eVox, manufactured by Evoke. This is a skull cap patients wear while brain functions are tested in 20-60 minute office visits. When Evoke released the device, they suggested general practitioners should bill with six different codes. However, the recommended codes require a longer testing time in a specialized environment, such as being in a soundproof or dark room. Furthermore, only certain types of specialists can administer tests with these codes. CMS said none of the codes were appropriate. Proper billing for use of the device involves only one code.
Claritev noticed several claims with multiple lines of billing codes for the device and took a closer look. Some physicians were billing with the six codes promoted by Evoke. We identified 934 claims with a total of $1.4 million in charges, impacting 335 patients, that were incorrectly coded.
Coincidentally, soon after we identified these claims we learned the U.S. Attorney Office of Eastern PA was litigating Evoke and its founding CEO for promotion of the billing codes.
They call it a panacea. We call it snake oil.
A Texas medical clinic claims a miracle infusion treatment can relieve symptoms of metabolic syndrome, rheumatoid arthritis, Parkinson’s, gout, macular degeneration, and Crohn’s disease. But wait, there’s more. The physician using the treatment says it also improves energy levels, sleep, inflammation, psoriasis, neuropathy, kidney failures, MS, and more. This treatment, dubbed “Physiologic Insulin Resensitization (PIR), is administered in three-hour sessions, up to twice a week, where doses of insulin and saline are pumped into patients via an IV every 4 to 8 minutes and offset with glucose given as sugar water, pretzels, or Coke.
Payors, including Medicare, reimburse PIR at approximately $500 per session. According to the CEO of a Texas hospital that offers the treatment, it’s wildly profitable. In fact, physicians using the treatment advocate for its use in every U.S. hospital. However, no credible clinical trials have confirmed PIR’s effectiveness, and a past president of the American Diabetes Association has implied PIR is fraught with deception, with a focus on making money. CMS has even refused to reimburse the code representing this treatment. To get around this, it’s now billed with a code representing infusions.
Claritev identified more than 15,000 claims billing for PIR, representing $5.2 million in charges and impacting 201 patients. We recommend our clients do not pay these claims.
Greasy palms handled these claims.
A group of Missouri and Texas physicians and medical practices were charged with accepting kickbacks for referring patients to specific laboratories for testing. These physicians and facilities violated the Anti-Kickback Statute, which prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid, and other federally funded healthcare programs. The Statute is intended to ensure that medical providers’ judgment is based on the best interests of their patients.
Claritev identified more than 251,000 claims with lab testing services from these providers, representing $130 million in charges and affecting approximately 32,000 patients.
The Department of Justice has financially penalized this group of physicians and facilities for the illegal kickbacks.
Learn more about Claritev’s Payment Integrity services and let us find out what’s hiding in your claim data.
