Posted and filed under Fraud, FWA, Healthcare.

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Are you, as a provider of services and submitter of claims, ready for the new changes to Evaluation and Management coding coming in 2021? In reading about these pending changes, my number one concern as a fraud, waste and abuse professional, is the deletion of the requirement for home visits to be documented with the medical necessity for the home visit.  Traditionally, when a provider performs a home visit, that encounter must have documentation to support why the patient was seen in the home and not in the office.  Although there is wide agreement that continuity of care may include a need for a “old school” house call, there is still a strong potential for fraud.

The problem with home visits is not the visit itself, it is the unscrupulous provider who goes door to door conducting “gang visits.”  I saw this many times with the OIG.  The provider sets up shop in a community room, and the patients literally would line up to be treated.  The treatment was no more than 3-5 minutes, yet the claim submitted was for anywhere between 30-40 minutes; sometimes exclusive of the added in Evaluation and Management code that was also billed.  With the removal of the documentation requirement to justify the home visit, the convenience factor can be part of the equation.  If a provider wants to make their practice solely dependent on seeing patients in a “captive” setting, such as a low-income, senior building, that is going to be fine with this new change.  I am in agreement that there needs to be more doctors who do the work of years’ past, but not at the risk of the Medicare Trust Fund, where captive audiences are an easy target.

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I think that this will be a new opportunity for fraud, waste and abuse, as convenience was not previously something that would be allowed to trigger reimbursement.  In the upcoming change, so long as the patient needs care, the convenience factor is allowed.  I truly hope that this becomes a highly monitored area, at least in the early stages.  Since the home visit codes are separate, it would seem that there can be data analytics and artificial intelligence models to identify outliers fairly easily.  A provider who was not doing a lot of home visit evaluation and management services and suddenly has an uptick, that is going to put them in the spotlight.

It will all come down to a combination of appropriate monitoring of any changes to a code, in conjunction with educating providers and beneficiaries.  Overall, the unscrupulous providers will always find a way to reinvent the wheel.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.