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.
One of the areas of reimbursement that has gotten very little discussion concerning the CARES Act is the funding that was provided to the Health Resources and Services Administration (HRSA). For those of you who are not aware, it is yet another piece of the HHS alphabet soup of departments. With over 300 departments, HRSA is probably more well known for its administration and management of the 340B pharmacy program. HRSA was provided with a large amount of money for providers continuing operations (direct payments based upon prior reimbursements) and reimbursement to providers for services rendered to patients for COVID-19 related issues and conditions when that patient is not otherwise covered by insurance.
HRSA is a small department, and during my over 20 years as a Special Agent at HHS-OIG, I had only peripheral involvement with this department, and only for understanding the very complicated 340B program (a topic for another day). What is interesting about the CARES Act funding (among other interesting things about the funding) is the process by which claims are adjudicated for this group of patients. First and foremost, the claims are being processed by a third-party commercial payor (similar to Medicare claims processing). Reimbursements are paid at the Medicare prevailing fee schedule rates, and the services must be relative to COVID. This is where the problem will be one that we in the fraud, waste, and abuse world will be pontificating and discussing long after we are all fully vaccinated and have moved on to the next news cycle.
The claims are submitted to payment through a special portal. As such, the presumption is that the claim for reimbursement is, by default, relative to COVID care. However, providers are being asked to self-attest that the service is for COVID related care, the patient is otherwise not insured elsewhere and there is an agreement not to balance bill the patient. In my reading of the program and discussions with those in the FWA world, it does not appear that generally, there are edits in place to reject certain claims. One would suspect that an evaluation and management code should be paid, as well as some diagnostic and therapeutic related services. What prevents an unscrupulous provider from signing up, attesting to everything, and submitting claims for durable medical equipment, services unrelated to COVID, and submitting claims to a patients’ insurance? This is a rhetorical question. Since there is currently no way to independently validate that the patient has an actual primary insurance, the potential for double billing is enormous.
I could write a very long story about all of the fraud that will surely be uncovered as a result of this well-intentioned program. This is a program that was quickly culled together to ensure the safety and health of the public. As with all public goods and programs intended to be social benefits, the floodgates will be open for FWA. This particular program, however, will present some very unique challenges to my friends at the OIG who be responsible for the investigations. HRSA is a small department, and I would suspect that the number of staff that can work on the FWA in conjunction with the OIG will be thin. As most of you who are keeping abreast of the latest and greatest in the COVID FWA world, I am keenly watching how this particular program and the frauds associated with it will evolve. At first and second blush, it just appears to be free money for the stealing, and it will be at the cost of people’s health, as there will come a time when the funding will be depleted, and care will still need to be obtained.
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.