Posted and filed under Compliance, Fraud, FWA, Healthcare.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

Hurricane Katrina and COVID-19, what do these two very different things have in common with each other? Both were events that wreaked havoc on the economy, triggered a healthcare crisis, and set payment models in a tailspin that took years to uncover and rectify.

Following Katrina, CMS, and many commercial payors following suit, suspended certain rules for, among other things, DME replacement. This was mostly the case concerning power and non-power wheelchairs. Of course, as you are reading this, why would anyone think that a non-power chair wouldn’t need an upgrade to a power chair. With almost no edits in place (through some modifiers allowing for the claims to be processed under a national disaster code), everyone got a power wheelchair. It was reminiscent of the Oprah show when “you get a car, and you get a car.” Suppliers were likely not able to keep up with the demand. 

How will this be similar to COVID-19? First and foremost, the changing, eliminating, and altering of the rules to allow some unprecedented services (such as telemedicine in the absence of a pre-existing relationship with a provider) are going to create huge gaps in the prevention of fraud, waste, and abuse. In a health emergency, we have to allow for some things to transpire that would not normally occur, or at least occur only after a proper vetting and implementation. We have yet to begin to see the tentacles of fraud schemes that we will see in the coming years.

We are looking at 30,000 feet at a problem that is operating at 2 feet. We are now seeing the prosecution of individuals for their “snake oil” remedies, installing fear in people to use a particular item, product or device to stay healthy, competing media outlets on the danger of COVID-19, tests that are bogus, kickbacks in return for referring tests, social engineers obtaining patient information to bill for services not rendered, and several instances of providers crossing over to commit frauds on other well-intentioned programs such as the PPP (see my prior blog about Dr. Ameet Goyal). 

For us in the FWA world, I never use the phrase “on the front lines”; we are not in a war or protecting the public from a raucous crowd. I have chosen to use those terms to describe those who are actually on a “front line,” like healthcare workers. We in FWA are merely cogs in the wheel of keeping the floodgates mostly closed. Take a look at what was done to combat the fraud in the post-Katrina world, and maybe think of how those tactics will work for COVID-19. Remember, there were multiple strikeforces, task forces, special units created to investigate the proliferation of fraud from Katrina. I have no doubt we will see that evolution. Law enforcement, payor communities, regulatory bodies, and anyone who was involved in payments provided as a result of COVID-19 will join together in collaborative ways, because that is what has to happen.

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.