Medical Reimbursement Data Management - MRDM Medical Payment Auditors

MRDM Auditor Highlights for your information and protection

OIG Review Highlights:

How to get a big poke in the EYE/Wallet!

An Ophthalmology Clinic in Florida: Audit of Medicare Payments for Eye Injections of Avastin, Eylea, and Lucentis (A-09-19-03025)

A Florida Clinic complied with Medicare billing requirements for intravitreal injections of Avastin, Eylea, and Lucentis. But they did not always comply with Medicare requirements when billing for other services provided on the same day (DOS).

The Audit identified 156 services billed that were not separately payable, and 70 services were not reasonable and necessary.

Auditor Note: This affects not only Government claims but also Commercial and Self-Insured claims and covers a wide range of services and procedures. MRDM’s advanced automated “Audit Engine Platform” analytics identifies these types of claims costing Employers and Employees hard earned healthcare dollars.

CMS estimated $215,606 of the $2.1 million paid to the Clinic for intravitreal injections of Avastin, Eylea, and Lucentis and for other services provided on the same day as the injections were not allowable for Medicare reimbursement.

Greed and Its Consequences for Small Hospitals and Their Communities

Marketing Promoters told Small Hospitals they could leverage their third-party payer contracts so that laboratory testing services done by out-of-network laboratories could be billed through their hospital payer contracts.

The marketing promoters and their legal counsel claimed that because no federal payers were involved in the arrangements, there was little or no risk to the parties involved.

How the Scam Worked

Patients who received lab testing were not patients of the hospital, but were patients generated by the marketers in distant markets or in different states from the hospital. An independent laboratory that did not hold third party payer contracts performed the lab testing, particularly toxicology and pharmacogenetic testing, and would invoice bill the hospital. The hospital would then re-bill the laboratory services with a price markup to its third-party payer contracts. The hospital realized a profit based on this markup in price. The marketers were paid a commission either by the performing laboratory or by the billing hospital for the marketing of the testing.

How it was Discovered (by chance)

An audit by the Missouri State Auditor’s Office noted that Putnam Country Memorial (rural) Hospital’s revenues over a 6-month period generated $92 million, compared to $7.5 million the year before. An insurance company in Florida started an investigation as did other insurance companies and the chase was on.

Auditor’s Comment: These pass-through type billing arrangements are violations of federal and or state laws and the dollars paid can be recouped by the 3rd-party payers based on lack of medical necessity for the testing, breach of contract, or false claims theories.

Unfortunately, many Payers use outdated utilization methods that may take several years if ever to identify these types of schemes. When a hospital or market company files bankruptcy, getting the money back is very hard.

MRDM designed an audit claim file field format for our Self-Insured customers based on EDI standards that we require from Payers to help identify many types of schemes. As Auditors it is important to understand if Payers are not requiring or not capturing these fields so we can advise our Self-Insured Employers the risk in their A*O agreements with Payers.

MRDM New Medical Technology, OIG Investigations & Cost Review Highlights:

MRDM reviews new medical technology, OIG Investigations and Cost implications to keep our Self-Insured Employers and employees ahead of the rapid changes in Medical Technology to develop strategies to identify new fraud schemes many Payers don’t do till costs are out of control.

1. FDA granted breakthrough device designation to “Impedimed’s” Sozo device for kidney failure. The bioimpedance spectroscopy device gives a more precise measurement for how much fluid should be removed during dialysis in a more precise manner to benefit patients over time. The current standard of care measures changes in weight between appointments which is a crude tool that can miss other causes for weight fluctuations.

Auditor Note: This may reduce a patient’s dialysis time reducing dialysis costs by increasing efficiency for Dialysis Centers. ESRD is very expensive and any potential savings cost improvements should be noted.

2. Medicare Trust Fund “Medicare Part A” (hospital insurance trust fund), will run out of funds in 5 years (2026.)

Medicare Supplementary Medical Insurance Trust Fund “Medicare Part B” (helps pay physician, outpatient hospital and home health services) is OK over the next 10 years.

OIG Investigations Highlights:

OIG - Duplicate Professional Fee Billing by Both the Critical Access Hospital and the Health Care Practitioner to Medicare Part A Hospitals.

Auditor Note: This is a problem for non-Medicare/Medicaid medical claims also. Our “Audit Engine Platform” identifies these as over-payments. Many Payer Adjudication Payment systems do not audit for this before payment.

OIG - Audit of Medicare Emergency Department (ED) Evaluation and Management (E&M code) Services
An ED is an organized, hospital-based facility for providing unscheduled or episodic services to patients who need immediate medical attention. ED E&M codes are only used for emergency department patients and must meet documented needs of the visit. All E&M codes services must be adequately documented clearly for medical necessity and coding destination for payment.

Auditor Note: MRDM reviews all E&M codes for coding guidance & documentation rules. There are 118 different E&M billing codes, each with a different payment amount. Our Audit Engine analyzes each E&M code because are the highest volume medical codes billed.

OIG - Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency
Phase two audits will include additional audits of Medicare Part B Telehealth related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring and use of Telehealth technology

Auditor Note: We focus on Phase 2 because Telehealth must be audited carefully to identify billing schemes associated with it. Any time there is money to be made, money WILL be made at the expense of others which is our mission to identify.

Telemedicine Schemes used to also Bill Low Benefit High-Cost Drugs, DME and other Services Increases

The COVID need has greatly increased the use of Telemedicine but has allowed this type of fraud to expand in the US.

In 2019 there were 98 qualified codes for Telemedicine billing.

Now in 2021 there are 271 qualified codes for Telemedicine billing and the list is increasing.

The Feds indicted and charged 24 individuals for Telemedicine fraud which included three licensed clinicians, five Telemedicine firms, 130 DME companies, and other medical professionals for a scheme using Telemedicine to defraud Medicare upwards of $1.2 billion.

MRDM Auditor Comment: Billing fraud schemes are agnostic and affect Government, Commercial and Self-Insured Employers so no one is safe.

HHS’s Office of Inspector General states nearly one-third of telemedicine claims reviewed did not meet Medicare requirements adding $3.7 million in additional costs, according to an OIG report.

MRDM has been tracking Telemedicine billing codes for years and understands their correct and incorrect use.

MRDM codified and digitized the rules for medical coding, billing and claim payment in all areas of medicine including certain areas in special pharmacy allowing it to develop its advanced “Audit Engine Platform” to automate medical claim payment auditing.

We are a medical auditing company and can act as an agent for Self-Insured Employers to audit their medical claims based on the Employer’s right to audit.

We understand the help Employers need to make informed decisions dealing with a Payor/A*O and important issues they need to understand that may be costing hard earned healthcare dollars.

Employers often fear dealing or changing A*O Payers because of their lack of knowledge.

mrdm.net

Self-Funded Employer Healthcare continues to expand MRDM Auditing Opportunities based on 2020 Survey

Employer-sponsored insurance covers approximately 157 million people. This is the twenty-second Employer Health Benefits Survey (EHBS) and reflects employer-sponsored health benefits in 2020.
HEALTH INSURANCE PREMIUMS AND WORKER CONTRIBUTIONS
In 2020, the average annual premiums for employer-sponsored health insurance are $7,470 for single coverage and $21,342 for family coverage. The average single premium increased 4% and the average family premium increased 4% over the past year. Workers’ wages increased 3.4% and inflation increased 2.1%.2 Note: 2021 Inflation is up over 2020

Self-Funding. 67% of covered workers, including 23% of covered workers in small firms and 84% in large firms, are enrolled in plans that are self-funded. The percentage of firms offering health benefits that are self-funded in 2020 is higher than the percentage (61%) last year.

Thirteen percent (13%) of small firms report that they have a Level-Funded Plan that combine a relatively small self-funded component with stop-loss insurance with low attachment points that may transfer a substantial share of the risk to insurers. Among covered workers in small firms, 31% are in a plan that is either Self-Funded or a Level-Funded Plan, 24% higher than the percentage (24%) last year.

Insurance companies’ traditional business model is broken because Employers moved away from their highly profitable Premium based coverage to A*O Self-Insured agreements that are highly price competitive but do not generate the revenues required to support their legacy and operational costs which is why they continue to shed employees and to merge.

They are moving out of commercial healthcare to Government Managed Care Medicare and Medicaid contracts that are much more profitable than A*O agreements.

MRDM is a medical auditing company and can act as an agent for Self-Insured Employers and can audit all medical claims over the period of an A*O contract based on the Employer’s right to audit.

MRDM codified and digitized the rules for medical coding, billing and claim payment in all areas of medicine including certain areas in special pharmacy allowing it to develop its advanced “Audit Engine Platform” to automate medical claim payment auditing.

We understand the help Employers need to make informed decisions how to deal with a Payor/A*O agreement. Employers often fear dealing or changing their A*O Payers because of their lack of knowledge.

Can good ideas be too Good?

Prescription drug utilization management and moves to counteract it introduces billions in costs to payers, providers, manufacturers, and consumers alike, a new report suggests.

Report, in the journal Health Affairs argues that such practices inflate already-too-high drug prices.

The research article concludes that utilization management practices could introduce as much as $93.3 billion to the U.S. health care system annually.

Some of the cost drivers identified in the article include:
• Payers for cost of “administering prior authorizations”.
• Manufacturers for cost of “administrative support programs,” “direct financial payments to assist commercially insured patients”.
• Physicians for cost of “providing insured patients with free medications”; for cost “physician practices’ time interacting with payers over prior authorization”.
• Patients for, “spending on branded drug cost sharing”.

Quantifying The Economic Burden of Drug Utilization Management on Payers, Manufacturers, Physicians, And Patients

New innovative but high-price drugs are causing payers to manage use and spending and by pharmaceutical manufacturers to support patient access and sales.

Payers are restricting drug formularies, requiring more stringent prior authorizations, and raising patient cost-sharing requirements.

Manufacturers are investing in programs that help patients and physician practices navigate administrative controls and help patients meet cost-sharing obligations.

Based on a compilation and analysis of the existing peer-reviewed and professional literature, this article estimates that payers, manufacturers, physicians, and patients together incur approximately $93.3 billion in costs annually on implementing, contesting, and navigating utilization management.

Payers spend approximately $6.0 billion annually administering drug utilization management, Manufacturers spend approximately $24.8 billion supporting patient access in response. Physicians devote approximately $26.7 billion in time spent navigating utilization management, whereas

Patients spend approximately $35.8 billion annually in drug cost sharing, even after taking advantage of manufacturer and philanthropic sources of financial support.

All stakeholders in the US pharmaceutical system would benefit from a de-escalation of utilization management, combining lower drug prices with lower barriers to patient access.

When Data is King who ever owns it is THE KING!

The American Hospital Association (AHA) recently asked the DOJ Antitrust Division investigate to block UnitedHealth Group’s planned acquisition of Change Healthcare Inc.

The AHA states the proposed transaction would produce a massive consolidation of competitively sensitive health care data and shift such data from Change Healthcare (see below), a neutral third-party, to Optum, a subsidiary of UHG the largest health insurance company – UnitedHealthcare – in the United States.

The combination of the Parties’ data sets would impact (and likely distort) decisions about patient care and claims processing and denials to the detriment of consumers and health care providers, and further increase UHG’s already massive market power.
• Change Healthcare is a provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers, and patients in the U.S. healthcare system.
• UnitedHealth Group Incorporated is an American multinational managed healthcare and insurance company based in Minnetonka, Minnesota. It offers health care products and insurance services.
• The American Hospital Association (AHA) represents around 5,000 member hospitals, health systems and other health care organizations including more than 270,000 affiliated physicians, 2 million nurses and other caregivers and 43,000 health care leader professional membership groups.

MRDM Payment Auditor Comment: UnitedHealthcare puts up walls to shield Payment data from review. As a provider in the past, I negotiated pricing with UHC and understand the AHA and other Medical Providers concern as Change Healthcare is a gold mine of competitive information that could give UHC the upper hand, more than they already have, against them. There is little trust between the medical community and UHC.