Making Sense of Healthcare Claims During Uncertain Times
Long before the global pandemic, healthcare payors have worked to ensure they were billed accurately and fairly. In the times of the novel coronavirus, the challenge has intensified. Consider that everything healthcare providers know about this insidious virus they are learning on the fly. New tests to detect it and treatments to cure it are being introduced at breakneck speed. Even care for long-existing illnesses has changed with many medical offices closed and providers practicing via telemedicine.
Dramatic Increase in Telemedicine Healthcare Claims
In May, 2020, market research firm Frost & Sullivan forecast that demand for telemedicine would increase 64% by yearend. Claritev’s claim data suggests quite a different trend. From mid-March through the first week of May, telemedicine claim volume grew 3,000%. As providers adjust to offering new treatments and new ways to offer care, the opportunity is ripe for billing errors and overpayment.
Payor Beware
Consider, for example, COVID-19 testing. Toward the end of the second quarter of 2020, the media reported several stories about the significant discrepancy in pricing for testing. A New York Times article highlighted two friends in Texas who were tested at the same time by the same provider. One received a bill for $199 while the other was charged $6,408. Even after the healthcare payor negotiated a reduction for the higher charges, the final bill was still over $1,000.
“As claims related to COVID-19 treatment ramp up, it’s especially important for healthcare payors to be extra vigilant in their efforts to ensure they are billed accurately and they aren’t overpaying,” said Chris Dorn, Senior Vice President of Payment Integrity at Claritev. “The newness of the virus, the frantic pace at which healthcare providers are working, and opportunists looking to take advantage of the situation create a perfect storm leading to potentially outright billing.”
Claritev’s Payment Integrity services address the following issues, among others:
- Price gouging and profiteering, including COVID-19 testing, COVID-19 treatment and durable medical equipment such as respiratory equipment offered at unreasonable costs.
- Billing for COVID-19 testing that has not been properly vetted and likely is not accurate. For example, there are no self-administered at home tests, yet certain providers are offering these test directly to patients.
- Misrepresentation of treatment. Focusing on those who are disguising experimental cures or preventative measures to fraudulently obtain benefit coverage.
- Unusual services during quarantine periods. For example, possible elective procedures being reported in areas where all elective procedures were canceled.
Payment Integrity Findings for Virtual Care
While the above focuses on the coronavirus, billing for telemedicine is also creating issues. During the months since the inception of the global pandemic, Claritev’s Payment Integrity team has identified several examples of erroneous billing. Here are just a few examples:
- A client submitted a claim where 75 minutes of acupuncture was coded as being delivered over the phone and included “electrical stimulation. Claritev’s Payment Integrity team caught the error and reduced the charges so that the provider was appropriately reimbursed for a patient telephone call.
- In another claim, Claritev’s Payment Integrity team identified a billing error by an orthopedic surgeon, who billed for a fracture reduction performed via telehealth rather than billing for a telehealth evaluation and management visit. Catching this specific error also reduced the amount paid on a claim because fracture reductions are reimbursed at a higher rate than a telehealth visit.
An Added Layer of Review During Uncertain Times
While many healthcare payors have internal payment integrity solutions to find errors, technology can only do so much. In these challenging times, it’s near impossible to keep up with all the potential issues that are emerging daily without a solution that includes manual claim review by healthcare experts. With profits hard to come by and every dollar meaning so much, it’s the perfect time to complement your existing internal payment integrity system with an external solution.
