A new rule took effect recently that requires commercial payors to provide reimbursement for in-home COVID-19 testing, at a rate of eight (8) test kits per person, per month.  Although well intended, the process for seeking reimbursement from commercial payors will be an utter disaster.  It is noted that government payors are excluded from this, and the rule only applies to the commercial space.

This is not a point-of-sale reimbursement situation; individuals will likely need to submit receipts for the kits.  From what I have been reading and hearing, insurance plans are struggling themselves to identify how the deluge of claims will be submitted for reimbursement.  In the normal course of business, insurance plans typically do not receive a huge volume of patient requests for reimbursement for out-of-pocket costs, so this will be a huge challenge. A way to potentially limit the fraud would be to have this become a point-of-sale situation, but the challenge is that many will make these purchases from pharmacies, who only have access to systems that allow for the submission of claims for pharmacy services.  At home kits do not have a CPT or HCPCS code, which exacerbates the problem.

Now to the issue that gives me the greatest pause; the volume of fraud, waste, and abuse that will engulf payors from false receipts that will be fabricated and altered to be reimbursed for kits that were never provided.  With the ease of software applications, it is a simple process to make a subtle change to a date to a receipt.  Will there be prosecutions for this; very likely not.  It is going to be in the same vein as the current estimated volume of fraud schemes that exist in laboratory COVID-19 testing. 

We are ever at a cross-roads with fraud, waste, and abuse in the COVID-19 world in which we are currently living.  Each day, and almost hourly, we see a new prosecution, a news article, or some other notification that another fraud scheme has been identified by the OIG, federal or state prosecutors.  I am personally exhausted from reading, watching, and listening to anything that involves COVID-19.  However, at the same time, I am also ever fascinated by the speed at which the criminal element pivots to adapt to the changing landscape.  The landscape comes from technology changes in testing and treatment, but also comes with the moving target of polices and reimbursement methodologies. 

The need for testing I think will continue to be a topic of discussion.  If you only test sporadically, is it worth the costs?  Does testing on a Monday, then testing on a Friday, but having been asymptomatic for the days in between, really matter?  There will continue to be a huge variety of scenarios that will continue to be brought up, and each scenario will lead to another fraud, waste, and abuse scheme.  It is up to the front-line payment integrity and fraud investigators to stay vigilant and continue to work on finding these schemes, with the goal of plugging the holes that are found as quickly as possible. 

We are doing a lot of work as retained experts in the COVID-19 laboratory world.  The litigation is there, and the work continues for us.  Our team of subject matter experts (SME) including our unprecedented team of retired Senior Special Agents and Supervisory Special Agents from the OIG, as well as our staff of policy experts with intimate knowledge of CMS policy, makes us a one-stop shop for this type of work.

By Eric Rubenstein