Back to the Basics, Other Payment Integrity Strategies Post-PHE

Back to Basics: Modifiers 24 & 25, Critical Care Codes, Place of Service

Healthcare providers underwent tremendous change during the COVID-19 PHE with the explosion of telehealth, persistent supply chain issues, and the modification of care delivery to combat labor shortages and emerging patient needs, to name a few. But these changes — even if some are here to stay — aren’t necessarily the focus of payment integrity and billing compliance.

“When you look at the media coverage, it’s COVID, COVID, COVID. And that’s important. There is a lot of enforcement around labs for COVID tests and respiratory panels, as well as the additional dollars that went out for support,” Kearney says. “But when you actually look at priority items for physicians and hospitals, it’s vanilla. It’s old stuff.”

Those old, vanilla items include modifiers 24 and 25 for evaluation and management (E/M) services, billing for critical care codes, and coding the incorrect place of service.

“These are things people focused on ten years ago,” Kearney explains. Yet, these billing issues continue to be high-risk areas for the federal government, she adds. The federal government is not exactly subtle about going after these areas for audits, too.

“The Department of Justice and all the Medicare contractors rely highly on data analytics and modifiers 24 and 25, as well as critical care codes, are really easy to monitor through data analytics,” Kearney states. “It’s really easy to pull claims that have code 24 and compare them, for example.”

For this reason, Kearney thinks items like incorrect location of service, critical care codes, and the like will always be a top priority for healthcare fraud enforcement.

“They’re just easier to monitor compared to clinical validation issues, which are always going to be more challenging,” she says.

That being said, COVID-related items are on the Office of the Inspector General’s (OIG’s) Work Plan. However, Kearney states that most of the action items are for provider types other than physicians and hospitals, such as laboratories and skilled nursing facilities.

“There’s not really a hospital-COVID focus because what the hospitals were doing was undeniable in a way that some other things weren’t,” Kearney contends.

Even telehealth isn’t really making the OIG’s radar in terms of hospital billing compliance. Kearney sees more compliance issues with telehealth platforms versus telehealth providers right now because there isn’t enough guidance and standards on telehealth billing yet.

The back-to-basics strategy

“What I’m going to say isn’t exactly revelatory: You should go back to the OIG Work Plan and see what’s on it,” Kearney says.

This back-to-the-basics approach is fitting after the expiration of the PHE a month ago, especially considering hospitals and physicians have both seemed to develop workflows and manage capacity better than they did early on during the pandemic. OIG itself has shifted back to similar auditing activities as before the pandemic, with the notable exceptions of some COVID-19 relief and testing investigations.

Focusing on those tried-and-true 60-day analyses will be key to this approach, according to Kearney.

The 60-Day Rule requires providers and other entities to report and return an overpayment within 60 days of identification and provide a reason for the overpayment. And healthcare fraud isn’t as black and white as in other industries; an overpayment may stem from an accident, but providers are still liable. That overpayment could become a reverse False Claims Act case.

Healthcare providers are held accountable for overpayments under the Rule because it defines identification of the overpayment to include when the provider identified it or should have identified it through reasonable due diligence, which includes proactive compliance initiatives.

“With respect to the 60-Day Rule, a lot of providers right now are finding issues,” Kearney states. “Is it just an overpayment or is it a bigger problem?”

Compliance teams may also want to take a look at their denials to identify any patterns that might signal a payment integrity problem, Kearney adds.

“I am seeing the Department of Justice ask for denials and not just from federal payers,” she says. "The government argues that if private payers are denying a bunch of claims, that is something that might put you on notice that you aren’t coding properly.”

Many healthcare organizations do not have a consolidated billing team looking at denials, which can make it difficult to identify patterns. Individual billers may handle certain accounts or types of denials, but Kearney encourages providers to be watching for trends and using comparative billing reports.

“These are things that have always been around, but comparative billing reports and PEPPER are important in terms of identifying things to audit,” Kearney explains, referring to the Program for Evaluating Payment Patterns Electronic Report, which includes provider-specific Medicare data statistics for discharges and services vulnerable to improper payments.

Similarly, healthcare organizations should really engage with Targeted Probe and Educate (TPE) audits if they occur, she adds.

“Use it as an opportunity for education and to see what you need to adjust,” she says.

A new post-PHE consideration

While the payment integrity strategy isn’t a novel cure for improper payments and healthcare fraud prevention, compliance teams should consider one major change in the post-PHE world: remote work.

“Anecdotally, I’ve seen more coders who are whistleblowers,” Kearney states. “My guess, which is anecdotal, is that it has something to do with people working remotely.”

A 2022 survey from AAPC, the nation’s largest education and credentialing organization for medical coders, billers, auditors, practice managers, documentation specialists, compliance officers, and revenue cycle managers, found that more than half of members work remotely.

Remote work allows organizations to tap into a larger pool of talent, especially in this tight labor market. However, having remote workers requires a different management style. The team bonding that comes with working in an office may not be as easy to achieve in a remote environment.

“Remote coders may not interact as much or have as many interpersonal bonds as coders used to in the office,” Kearney explains. “That might mean they are not as inclined to give people the benefit of the doubt or not as willing to bring a coding problem to their supervisor so the facility can fix it.”

Compliance may not seem “touchy-feely,” but that is an important aspect of running an effective compliance team, she adds.

“A piece of advice I give to people when they ask how they can prevent a False Claims Act case is having an approachable person who wants to know about any compliance concern,” Kearney says. “When someone brings up a concern about a billing practice, that person needs to be thanked and celebrated.”

Following up with a concern and changing a best practice if necessary is also key to preventing healthcare fraud and potential whistleblower cases. Failing to respond to an email may come off as indifference or, worse, as if you know there is a problem and you don’t want to address it.

Revising management style is necessary in this post-PHE world as healthcare organizations get back to the age-old problems with payment integrity and billing compliance.