As COVID-19, respiratory syncytial virus (RSV) and other infectious diseases have spread over the past four years, waste and abuse in healthcare claims billing relating to these conditions has increased. “There is a lot of interest in how COVID, RSV, and infectious diseases in general, are impacting the healthcare waste and abuse segment,” said Francine Way, Senior Director of Strategy and Operations Planning of Claritev’s Payment & Revenue Integrity division. “Healthcare payors need to understand how their payment integrity vendor is fighting this growing trend.”
While existing methods of identifying waste and abuse will find some of the occurrences, they won’t pick up all because some bad actors have modified their existing billing methodologies to capitalize on the new opportunities. According to Fraud, Waste, and Abuse in the Context of COVID-19, a white paper published by CMS, “in fiscal year 2020, the Department of Justice (DOJ) opened 1,148 new healthcare fraud investigations, consistent with the number of annual investigations observed over the past decade.” The paper noted that because schemers adjusted their tactics during the pandemic, efforts to prevent and mitigate fraud, waste and abuse must also adapt.
Lab testing for COVID-19 and other infectious diseases is one area ripe for waste and abuse. The following are examples involving infectious disease claims from laboratories:
- To investigate the surge of fraud that occurred during the pandemic, the Department of Justice created a special task force. One of several schemes they uncovered involved two owners of a clinical laboratory in California who fraudulently billed for more than $214 million for lab tests—more than $125 million of which involved fake claims during the pandemic for COVID-19 and respiratory pathogen tests.
- In Georgia, a lab owner pled guilty to felony charges and the owner, along with the clinical laboratory that he owned, agreed to pay $14.3 million to resolve claims related to kickbacks and unnecessary testing.
Waste and abuse relating to COVID-19 and other infectious diseases is becoming so widespread that the National Health Care Anti-Fraud Association (NHCAA) recently reviewed infectious disease processes for their vulnerabilities to abusive billing and coding behaviors in a webinar. Long before the webinar took place, Claritev enhanced our procedures for identifying related waste and abuse.
To see what we’re doing to identify waste and abuse related to infectious disease claims, download our white paper titled “Innovations in Payment Integrity: Stopping the Spread of Waste and Abuse Related to Infectious Disease” and don’t forget to ask your payment integrity vendor what they are doing.
Download the white paper
