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Leverage payment integrity solutions to ensure proper billing of tele-health services

Don’t be surprised if the U.S. Department of Health and Human Services continues the COVID-19 public health emergency in mid-July, based on what government officials have said.

If it ends, however, the news will be cushioned by a five-month extension to tele-health flexibilities that were created during the coronavirus pandemic. That extension was granted by Congress as part of the sweeping omnibus spending bill approved in March.

Those accommodations will provide patient-centric benefits of access to providers, allowing adults aged 65 or more years, including senior living residents, to use Medicare coverage for tele-health visits, regardless of location. Under those flexibilities, all Medicare-enrolled providers can bill for tele-health services taking place from the patient’s home as well as from medical facilities. The bill also will postpone the requirement that older adults who seek virtual mental healthcare have an in-person follow up appointment within six months, taking the strain off of medical staff and caregivers coordinating those visits.

Although the benefits to patients are clear, greater tele-health flexibilities create more room for healthcare billing fraud, waste and abuse, or FWA, through potential coding and payment aberrations affecting payers and providers alike. Pre-pandemic, claim-related FWA was a top issue for health plans aiming to evolve both care quality and consumer experience expectations. The pandemic, however, created the need for overhauled payment integrity solutions, including complete process re-engineering and AI, automation and analytics enablement.

As payers and providers grapple with compounding operational challenges across the board due to the COVID-19 pandemic, their relationship is strained further due to gaps in knowledge surrounding ever-changing Centers for Medicare & Medicaid Services guidelines and documentation requirements for smooth claims processing. Those learning gaps often intensify billing and coding errors between providers and payers.

To prevent further strain on back-office staff members, providers must consider partnering with trusted third parties to ensure proper billing processes and coding. Payment integrity solution providers are key in driving improved accuracy of information between provider and payer to ensure there isn’t a post-pay audit issue associated with the par/non-par provider in relation to new regulations around billing processes.

In April, the Department of Health and Human Services Office of Inspector General, along with their law enforcement partners, participated in a sweeping, coordinated law enforcement action to combat COVID-19-related healthcare fraud.

Twenty-one defendants in nine federal districts across the United States were charged for their alleged participation in various healthcare fraud schemes that exploited the COVID-19 pandemic and resulted in more than $149 million in false billings. Defendants included telemedicine companies, physicians, marketers and medical business owners.

With the growing prevalence of tele-health came increasing risks of coding e-visits or virtual check-in claims to higher-level tele-health visits, as well as up-coding of evaluation and management services to a higher level of service than actually rendered. According to Medical Billing Advocates of America research, 80% of medical bills contain errors, and although the expansion of reimbursable tele-health services may drive an increase in such errors, a need to educate providers to change their billing patterns becomes increasingly important. To combat these billing errors, highly trained coding resources are needed to ensure that compliance standards are met while still providing cost and operational optimization, with the implementation of new tools, such as analytics, AI and automation.

As expert problem-solvers, payment integrity solution providers can use their exposure and understanding of the nuances of the COVID-19 tele-health impact to assist payers and providers in navigating changing regulations, documentation requirements, and how they can affect business from an end-to-end perspective. With the right payment integrity approach and attention to detail, providers will be able to focus on quality of care while thriving in today’s environment.


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