The HRSA Fund was created at the height of the COVID-19 pandemic to make testing available for the uninsured. The program had specific requirements for validating that a patient was uninsured. New diagnosis, procedure and testing codes were created and certain special waivers were put in place, leading to potential misuse and misconduct.1
Risks Our Experts See Increasing
The HRSA Fund was created at the height of the COVID-19 pandemic to make testing available for the uninsured. The program had specific requirements for validating that a patient was uninsured. New diagnosis, procedure and testing codes were created and certain special waivers were put in place, leading to potential misuse and misconduct.
Our experts are seeing a rise in regulatory scrutiny related to miscoding of COVID-19 tests and associated provider visits that often lead to an overpayment. For other government payers, regulators such as CMS, HHS, DOJ and OIG may be questioning the frequency of testing performed on some patients or the codes that are being billed in conjunction with COVID-19 lab tests. In addition, both commercial payers and regulators are questioning the fees (price gouging) along with the bundle of services charged and reported for COVID testing.2
How We Help
Our experts support providers, health plans, and testing laboratories to ensure compliance with billing and coding as well as through investigations and disputes.
Internal Proactive Compliance
Our experts provide 3rd party assessments of risks associated with Federal funding (including HRSA, Medicare, Medicaid) and covid testing. We help clients ensure compliance, identify potential risk areas, and remediate any historical issues.
Billing & Coding
We provide guidance on the use of COVID-19 testing codes based on the lab requirements associated (i.e., CLIA-waived, CLIA Independent or high complexity lab, etc.), as well as guidance related to additional codes that providers may have been billing in conjunction with the testing codes. For providers who billed a separate code although the actual test collection was embedded in the evaluation and management (E/M) visit, our experts help clients to assess repayment needs and correct related issues going forward.
Investigations and Disputes
Clients rely on our advanced data and analytics capabilities to support them through investigations and disputes. Our team brings extensive experience with lab billing and pricing disputes and investigations including experience serving as an IRO to support our clients. We also have economists on our team who have dealt with price gouging and economic issues.
Billing & Coding Compliance for a Healthcare Provider
Situation: An urgent care provider that administered COVID tests during the pandemic engaged our experts to assess whether the appropriate lab test codes were utilized and whether the appropriate E/M codes were billed for those visits.
Our Role: Our client was concerned that medically necessary and appropriate E/M codes were not billed according to CMS guidance and that incorrect COVID-19 testing codes were utilized.
Our Impact: Through data analysis we identified which COVID-19 testing codes were billed in order to determine whether the appropriate code was utilized and if not, whether there was a corresponding repayment. We also assisted our client in determining that certain codes could not be billed in conjunction with E/M codes, and whether the E/M code billed was supported by the documentation. Our work resulted in a repayment to certain Federal payors, and an update to their internal policies.
Economic assessment of Covid testing prices
Situation: A regional health insurance company filed a complaint against a Covid testing laboratory for price gauging and performing unnecessary tests.
Our Role: FTI was retained as an expert witness to perform an economic analysis of the lab's posted cash price for COVID-19 testing to determine whether the prices were excessive as compared to prevailing market prices for similar services.
Our Impact: Our analysis, assessment and report led to expedited settlement favorable to our client.
Internal Audit of National Testing Laboratory
Situation: A national testing laboratory requested an internal audit of its HRSA Covid claims
Our Role: FTI conducted an audit based on a sample of the lab's HRSA claims which included a review of the patient questionnaire and consent form, insurance eligibility results and physician requisition order.
Our Impact: Audit finding results were used by the client to improve internal processes and controls.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.