The Corporate and Financial
Investigations Department (CFID) at IBC continues to address the rising cost of
health care by identifying, investigating, and reporting suspicious cases of
fraudulent and abusive practices to law enforcement authorities. In addition,
CFID is responsible for conducting audits of billing activity for facility,
professional, and ancillary service providers.
During 2012, CFID received over 1,000
allegations of fraud, waste, abuse, or aberrant billing practices. More than 75
investigations were initiated. Audits were conducted on 148,266 hospital
claims, 349 professional providers, 2,791 pharmacy drug utilization desk
audits, and 377 pharmacy retail sites.
Evidence gathered through these
investigations resulted in 38 referrals to law enforcement or regulatory
authorities. Grand Jury indictments and the filing of criminal information
charges were brought against eight individuals. In addition, 16 guilty pleas or
convictions resulted in sentences ranging from probation to 72 months
incarceration.
The fraud schemes most often
used were:
- billing for services not
rendered;
- up-coding procedure codes in
order to receive higher reimbursement;
- submission of false
claims;
- prescription fraud.
The investigations and audits performed
or facilitated by CFID in 2012 resulted in approximately $69 million in
recoveries of overpaid claims, with an additional $4.2 million identified but
not yet recovered. Over the last ten years, CFID has recovered more than $476
million in overpaid claims.
Based partially on the positive
national reputation achieved by CFID, IBC was one of four Blue Cross? Blue Shield?
Plans asked to participate in a joint federal government, state agency, and
private sector Health Care Fraud Prevention Partnership to help address the
rising cost of health care in America.
Questionable billing and coding
practices and trends identified during 2012 will result in increased audits in
2013 in the following areas:
Facility provider audits
- Credit balance audits correct
overpayments that can adversely affect balance sheets of both IBC and its
hospital providers.
- DRG audits focus on the
correct coding of documented medical information by analysis of medical records
for inpatient claims.
- IBC medical policy audits
ensure that facilities are aware of and follow IBC medical and claim payment
policies as they pertain to our members.
- Outpatient fee schedule
audits select claims for review based on either government edits or on those
procedure codes that have been identified as frequently miscoded and
incorrectly billed.
- Readmission audits
pertain to an unplanned inpatient hospital admission within three days of
discharge from a previous inpatient hospital stay and for a condition directly
related to the original inpatient hospital stay.
Professional provider audits
- New patient evaluation and
management (E&M) code audits verify that a member has not received a new
patient E&M service within the past three years from multiple physicians of
the same specialty in the same group.
- Single- versus multiple-unit
audits ensure that the correct units are billed, as defined for CPT? codes.
- High-dollar medication audits
focus on high-dollar medications that are administered in a physician?s office
to ensure the accuracy of claims billed.
- Duplicate billing audits
ensure that duplicate claims are denied appropriately.
- Split-billing audits look at
claims for the same member, from the same provider, for the same date of
service and visit.
- Modifier 25 audits look at
E&M codes billed with modifier 25 on the same day as preventive medicine
codes were billed. This process ensures that the E&M service was for a
significant and separately identifiable service from the preventive medicine
service.
- Inpatient and outpatient
E&M service audits ensure that appropriate levels are billed and paid,
including consultation codes and the use of modifiers 24 and 25 with E&M
claims submissions.
- Office site-of-service
audits ensure that services receiving a site-of-service differential were
rendered and billed in the office where the service took place.
Although CFID?s ongoing efforts are
effective, we still need your help. The sophisticated software data-mining
tools used and our toll-free hotline provide valuable leads, but there is no
substitute for your vigilance. Allegations received from our provider community
are extremely valuable; therefore, we ask you to continue to contact CFID if
you are suspicious of any questionable health care activity.
You can contact us by calling our
toll-free Corporate Compliance and Fraud Hotline at 1-866-282-2707 or by going to www.ibx.com/antifraud and filing an
electronic report.