Forensic AI Alerts: Mid-Year Roundup

Educating Today’s Healthcare Executives with Game-Changing Knowledge

Cost containment is a major priority for healthcare executives who face challenges like high prescription costs, staff shortages, and an ever-changing landscape of treatments and billing protocols. Research shows that healthcare costs have increased by 5.6% this year, and by an average of 4.8% since 2021. Fraud, waste and abuse (FWA) are a significant contributor to ballooning costs, with an estimated $380B lost each year. This inevitably leads to higher premiums and out-of-pocket costs for patients, as well as reduced benefits and coverage.

Working closely with healthcare payers, agencies and pharmacy benefits managers, we understand the FWA they are seeing in their day-to-day transactions, enabling us to analyze how their challenges translate to the broader healthcare industry. Their top-of-mind issues include areas such as:

• over- or improper use of popular prescription drugs,
• questionable billing of services, and
• lack of clarity about the latest coding guidelines.

Aside from helping our clients manage FWA threats with innovative AI technology, we proactively offer advice to help make data-informed decisions and protect their bottom lines with monthly Forensic AI Alerts. These informative industry bulletins offer insights on the latest FWA trends with timely assistance for tracking and managing code changes, compliance mandates and new developments in fraudulent schemes.

Timely knowledge and insight can be a game changer. Let’s explore some of the FWA themes we’ve uncovered with AI Alerts in the first six months of 2023:

Evaluating Inappropriate Billing with Trending Services

Billing discrepancies are on the rise for telehealth services, as well as within specialties like psychiatry, both with wrong code usage and reporting of evaluation and management (E&M) services.

The COVID-19 pandemic led to a telehealth usage spike of 70% in 2020. Three years later, the use of telehealth medicine continues to evolve as patients maintain their use of these services. One evolution of telehealth medicine is the growing trend of delivering audio-only services. In our January 2023 AI Alert, we share how using Codoxo’s Fraud Scope Query Builder can help clients assess improper use of Modifier 93. Some additional tips for monitoring these suspicious trends include looking for other services billed for the same patient and/or same date of service, such as lab tests or other procedures billed by the same provider, excessive use or high-volume utilization of Modifier 93, and determining if it makes sense for the geographic area where the patient lives.

Another growing trend since the pandemic includes telephone Evaluation & Management (E&M) services. In our April 2023 AI Alert, we share the CPT codes and the criteria for use of telephone E&M services. To better understand what telehealth scenarios your plan might find within your claims traffic, we offer three examples — like a parent/son telephone discussion with a physician regarding parent’s memory loss — to support the discovery of this FWA.

Given the increase in psychiatrists performing psychotherapy services and billing a high-level of E&M service on the same date, our May AI Alert offers guidance for reviewing claims of this type, along with applicable psychotherapy CPT codes to report with an E&M code.

Assessing Proper Utilization and Coding of High-Demand Drugs

Another recurring theme has been high utilization — and potentially improper use — of drugs to treat chronic conditions.

Mounjaro, Wegovy, and especially Ozempic, have become popular in the news and online as weight-loss miracle drugs. However, because of the strong demand for these medications, patients with medical necessity for these drugs, especially type-2 diabetes patients, are having a difficult time accessing their medication. In February’s AI Alert, we flag the escalation of the off-label use of these drugs, the subsequent impact to priority patients, and the responsibility of health plans to monitor for improper use. We recommend health plans review any policies related to these medications including preauthorization, prerequisite conditions, treatment periods, and off-label utilization in the non-type 2 diabetic population. See how Codoxo’s Fraud Scope can assist health plans with assessing weight loss drug utilization.

Because of its growing potential for FWA, we circle back to weight-loss drugs in our June AI Alert, advising readers that product shortages and high cost are leading some patients to seek alternatives – including counterfeit medications without key ingredient semaglutides – and supplement replacements to Ozempic and Wegovy.

Additionally, we spotlight the high utilization of chemotherapy injections by allergy and immunology specialists for treating eosinophilic asthma and severe asthma. Oftentimes, the injections were given in the physician’s office multiple times per patient and the claim details for the ‘J’ code indicated the drugs were billed from their office stock. To navigate this FWA, we provide detailed guidance in our March AI Alert for reviewing CPT codes associated with Benralizumab and understanding what to consider when reviewing autoinjector drug claims.

Healthcare professionals, billing experts and payers must be armed with the latest information and technologies so they can carefully and accurately watch for discrepancies and protect their bottom line.  Looking to dive deeper into any of these topics? Below are links to the Forensic AI Alerts previewed above, and we invite you to check back regularly for new information about the latest trends and FWA schemes.

• January 2023: Coding and Billing for Audio-Only Delivered Services using Modifier 93
• February 2023: Gains and Losses with Weight Loss Prescription Drugs
• March 2023: Take a deep breath when reviewing asthma treatments
• April 2023: Telephone E&M Services: When to “Make the Call” for Records
• May 2023: Psychiatrists Performing Psychotherapy Evaluation & Management (E&M) Services Requests
• June 2023: Weight-loss Drug Shortages: Breeding Ground for Fraud and Future Health Issues

To speak with a Codoxo team member about how we are using artificial intelligence to reimagine healthcare, please contact info@codoxo.com.