Industry experts focused on improving the healthcare fraud investigators' clinical understanding and offered legal advice and compliance tips for special investigation unit leaders at this week's National Health Care Anti-Fraud Association's (NHCAA) annual training conference in Orlando, Fla.
Here are four of the insights shared during Tuesday's sessions:
Red flags for potential fraud: Prolotherapy, mesotherapy and subtalar arthroeresus are universally considered investigational services, so no payer pays for them--yet claims can fly through the system, according to Gary Cicio, M.D., clinical director for fraud investigation at the insurer WellPoint. He recommends using provider locator websites to find docs in the area that provide those services. If they're top heavy in those procedures, perform a retroactive audit.
What to look for when data mining: To root out upcoding, unbundling, or other improper billing and coding, first find providers with a high use of certain codes, such as CPT codes 20670 and 20680 for the removal of "buried hardware," Cicio noted. Payers can look back in a providers' claims history four to six weeks prior to the removal. Then identify the surgical event that caused the material to be impanted and later removed to determine medical necessity.
Audit preparation best practices: For audits, a good defense is a good offense, so stay on top of staff and make sure they understand all fraud, waste and abuse policies and procedures and federal regulations, Dave Popik, senior director of the SIU at Florida Blue, said. Also, align their performance metrics with FWA standards. Doing so holds investigators and managers accountable, added Cigna Audit Director Tom Hixson. Once payers get an audit notice, they should assign an audit coordinator, who is charged with clarifying everything throughout the audit process and getting everything in writing.
What auditors want to see: Auditors aren't just looking for fraudulent activity: They're looking across the board for fraud, waste and abuse, Hixson noted. And auditors really want to know the timelines of activities and documentation, Popik said. That includes whether cases are up to date, how long it takes payers to handle complaints and the amount of completed fraud, waste and abuse training. What's more, auditors might even call a payer's fraud hotline to ensure efficiency.