Posted and filed under Compliance, Fraud, FWA.

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.

Over the past couple of weeks, I have seen an unbelievable number of posts on the various social media feeds about people being admitted to hospitals for various conditions that were unrelated to COVID-19, but that their death certificate had some reference, or there were other signs that the hospital was connecting the current illness to COVID, under the guise that the hospital will be paid more. Without doing any data reviews, internet research on the payment methodology, or any of the other empirical reviews, it is easy to see that this could and, quite possibly is, occurring. 

With diagnosing patients with COVID being much more prevalent than it was from the beginning, and even until just recently, the ability to document that a patient did have COVID would be difficult to disprove. Patients presenting with some of the common COVID symptoms of fever, cough, aches, etc., might have had some other ailment (the flu, pneumonia, etc.). It would be fairly simple to submit claims for reimbursement for COVID. Without a definitive diagnostic test to disprove that assertion, the claim will likely sail through. 

I would even suspect that in an audit occurring (and anyone that does not believe that the audits will be fast and furious, I have a bridge I would like to sell you), I would suspect that a hospital that gets denials in a post-pay environment, would have a strong leg to stand on in arguing to the contrary; even if the claim was falsely submitted to obtain any higher reimbursements. The simple fact is that these are unprecedented times concerning claims processing and payment, and uncharted waters concerning fraud, waste, and abuse. The number of articles that I read daily, the number of conversations and calls that I participate in on COVID, really would make your head spin. 

As I often opine, and as many of our fellow documentation improvement experts (several of which work directly with Advize on these very issues) have stated, from a fraud, waste, and abuse perspective, the devil is in the details. If any provision is seeking to capitalize on COVID from a financial perspective, and there are a multitude of legitimate methods, have at it. Providers should be paid for the appropriate level of effort, and that effort needs to be properly documented. The Advize team knows the ins and outs of MAC, UPIC, and commercial payor audits in ways that are true differentiators. Our staff of auditors, retired OIG staff and former “Big 4” accounting and advisory firm management, have a very unique perspective.

We have worked on both sides; payor and provider. 

 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.