How Payment Analytics May Help Medicaid Programs Decrease Fraud, Waste, And Abuse.

Unfortunately, large-scale tragedies and periods of significant transition, such as the one we are presently experiencing, are fertile ground for fraud and abuse.

 

The current health-care environment has highlighted the need of preserving and supporting various modes of health-care delivery and public-health initiatives. Unemployment and the economic crisis caused by the epidemic have led to increasing enrolment in safety net programs like Medicaid in many states. At the same time, a shaky economic environment has resulted in lower revenues and more volatile budgets. States have been coping with the additional strain that COVID-19 cases place on the health care system in addition to managing this flood in safety net program participation, which is a difficulty in and of itself.

Various processes, rules, and regulations at the national, state, and local levels were put on hold or simplified in the early months of 2020 to help boost patient capacity and access to health care. The simplified telehealth regulations, which allowed clinicians to quickly begin giving virtual care to patients, were particularly notable for many patients.

 

These adjustments were important to address pandemic-related medical delivery and access issues, but they also introduced additional complications. Many of the programming improvements at hospitals and health systems, for example, were focused on program integrity (PI) and the avoidance of fraud, waste, and abuse (FWA). In the commercial payer world, program integrity refers to the function of ensuring that health care services are correctly billed and paid as rendered. It is a critical component of ensuring state agencies’ sustainability and efficiency, as well as the programs they provide and the people they serve.

CMS, state governments, and payers took steps in early 2020 to stop numerous preventative programs linked to PI and FWA in order to focus available resources on care access and capacity. During the public health emergency, certain states, for example, stopped in-network hospital and emergency service reviews. Unfortunately, large-scale tragedies and periods of significant transition, such as the one we are presently experiencing, are fertile ground for fraud and abuse.

As the country recovers from the epidemic, it is critical to restart these services swiftly and efficiently to ensure speedy economic recovery and the protection of safety net programs. States must reconsider the structure, process, and technologies that underpin such programs, beginning with a few key priority areas to ensure that important program integrity activities are sustained and maintained.

 

Keeping coding and invoicing errors to a minimum

It would be an understatement to suggest that billing has become more sophisticated, convoluted, and error-prone with the implementation of COVID-19. The addition of new telemedicine codes, as well as new coding criteria for COVID-19, has opened up a slew of new possibilities for billing errors. As with every new code, there will be some uncertainty about how to use it, which will be exacerbated by increasing stress for both physicians and the health-care system.

Payment analytics, when used as a key component of program integrity initiatives, can help states save money and recover money by assuring payment accuracy every time. When claims are billed improperly, modern payment analytics technology can assist immediately identify these claims so that they can be avoided or promptly recovered without the need for medical records.

When it comes to pre- and post-pay claims review and editing, for example, advanced analytics can help to automate the process so that claims can be rapidly verified for errors and potential abuse. Claims automation technology not only aids in accurate coding and billing processes, but it also assists states in remaining compliant. An automated editing procedure rapidly validates compliance and protects companies from inappropriate overpayment by preventing improper billing issues.

Payment analytics provide states with the information they need to better identify and avoid invoicing errors. As a result, states are better positioned to reduce the risk of incorrect payments, recover overpayments more quickly, and contribute to the greater goal of reducing health-care spending and costs that jeopardize state program sustainability.

 

Detecting and preventing fraud at a time when vulnerabilities are at an all-time high

Detecting, preventing, and responding to Medicaid fraud and abuse incidents is a difficult but critical endeavor, particularly during the pandemic, when telehealth systems and technologies were quickly rolled out and adopted across the country.

Fraud and abuse have always thrived in the telemedicine industry, which was exacerbated by CMS’s extended coverage and looser restrictions during the pandemic. An unprecedented amount of telehealth claims and a heightened risk of error have resulted from the industry’s high adoption of virtual services. The increased risk of fraud and abuse, from false claim filing to prescription drug forgery to ransomware attacks, has necessitated states doubling down on payment accuracy analytics to help identify patterns and abnormalities in claims that signal potential fraudulent events before the damage is done. A high-profile telehealth pharmacy fraud case involving $174 million in claims paid by private insurers, Medicare, and TRICARE, in which patients were administered unnecessary, expensive, or inaccurate drugs was only one of many examples.

Having a Medicaid fraud and abuse service in place, like in the example above, gives comprehensive visibility to facilitate effective fraud detection. States must have the analytical capability to explore the full range of care options, including fee-for-service and managed care, to ensure that nothing goes unnoticed. For example, data visualizations can aid in the creation of accurate peer comparisons as well as the detection of unexpected trends and outliers. Furthermore, technology can assist in automating and standardizing this previously time-consuming procedure. Traditional program integrity audits, which were effective prior to the pandemic, may now fall short due to a surge in telehealth claims and reduced payment rates. Automated solutions are proven incredibly beneficial and successful in identifying fraud and abuse related to telehealth services for states wishing to strengthen program integrity efforts.

As the country navigates health care’s new normal and the era of virtual care and telehealth, bolstering program integrity efforts, such as advances in claims and billing processes, could result in millions of dollars in savings for state Medicaid programs at a time when bolstering safety net programs and containing health-care costs are critical.

 

 

 

 

Source: https://www.benefitspro.com/2022/05/18/how-payment-analytics-can-reduce-fraud-waste-and-abuse-in-medicaid-programs/