Newly approved procedure codes, devices and DME are like the watering holes on the Serengeti. They are gathering spots for fraudsters and great hunting grounds for those looking to identify and stop the FWA.
As a fraud hunter, you must follow the data trends to see what new codes or patterns of codes are spiking. From there, you single out the target by identifying what specific providers are driving that spike. In the slide above, the code 99417 was approved as a new E & M code for prolonged visits.
So, look for the providers that are taking advantage and billing it more than their peers. Same would be true for any newly approved devices and equipment. Chances are the edits and policies may not be finalized. For these, pay special attention to the diagnoses of the patients. Devices and equipment may be approved for specific purposes but marketed, sold and used for others – so there may be coverage issues as well as medical necessity.
Utilize medical review and interviews to gather more information and hopefully you will stop the wrongdoing before it gets bigger.
Happy hunting!
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