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FWA Insights: Examining a suspicious volume of HCPCS codes

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Behavioral health is unfortunately often targeted by bad actors as an opportunity for exploitation. The esoteric nature of behavioral services can be vulnerable to fraud, waste, and abuse (FWA) due to a lack of physical symptoms. But investigating FWA in behavioral health can boil down to flagging suspicious billing patterns and due diligence. In a recent case, Cotiviti’s special investigations unit (SIU) flagged suspicious activity from a provider exhibiting strange billing patterns for HCPCS codes H2014 and T1017.

Suspicious billing: HCPCS H2014 and T1017

Healthcare Common Procedure Coding System (HCPCS) codes are used to report medical procedures, supplies, and services to Medicare, Medicaid, and other health plans. A mental health provider submitted claims with specific codes at a higher frequency than peers. The submitted high-volume codes were for:

  • HCPCS H2014, a code listed under Alcohol and Drug Abuse Treatment Services/Rehabilitative Services for 15 minutes of skills training and development
  • HCPCS T1017, a code listed under State Medical Emergencies for 15 minutes of targeted case management

This provider billed seven members for these codes exclusively, with the same number of units for each code for each member 100% of the time. The provider also billed three hours for each member on each date of service.

Erroneous place of service

In addition to submitting a suspiciously high volume of identical claims, the provider listed billing practices that reflected impossible hours. The data showed that the provider billed several dates of service for two sibling groups of two members, each group sharing a home more than an hour away from the provider’s office. The providers billed three hours of services per day per member in both of these groups despite the distance, spending six hours in each home. Additionally, the provider billed several consecutive days in a row that included spending six hours in one home and then spending three hours in another home located 90 miles away. This would mean that the provider claimed to have spent six hours in one location and then allegedly drove hours away to spend three hours at another home. All of these abnormal distances and services proved problematic, and likely a case of impossible hours.

Cotiviti also determined that the provider’s listed location was a residential home, not an approved location for individuals to go to receive behavioral health services, making it unlawful for services to be provided at this location. The listed property owner of the residential homestead was neither the owner of the business nor the rendering provider. This information was verified through the local county tax appraisal district.

A thorough investigation

Investigators reviewed claims data for the provider’s 18-month billing history, which identified potential excessive services. Peer comparisons identified the provider as an outlier among peers for the suspect procedure codes: The provider received seven times more payment for HCPCS T1017 and 21 times more payment for HCPCS H2014 than the peer average.

As a result of our data analysis, records were requested for the seven members billed to determine if the services had been provided as billed and paid for. The total payments at risk for the seven-member sample reviewed is $78,000.

Abnormal behavior

After Cotiviti reached out to the provider for verification, a number of suspicious behaviors ensued:

  • The provider did not respond to medical record requests.
  • The provider’s website is no longer active.
  • The provider’s toll-free number is now disconnected, the local number is a cell phone that goes straight to voicemail, and phone calls were not returned.
  • The owner is listed as a counselor; however, no license can be located.

All sampled claims were deemed not supported for failure to provide records and the case was referred to the state’s Office of Inspector General and attorney general. The plan also plans to conduct an on-site visit to verify the provider’s location and attempt to obtain medical records.

Looking to learn more about how your plan can manage FWA? Read our latest eBook, FWA Insights: 6 areas of healthcare and how to defend them against fraud, waste, and abuse.

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About the Author

Melanie Poole, RN, AHFI is the FWA Director for Cotiviti, responsible for Cotiviti’s FWA solutions where she leads a team of investigators and medical review auditors to drive strategy and market offerings. Prior to joining Cotiviti, Melanie was a special investigations unit (SIU) investigator for a Maryland-based health plan. She is also a registered nurse (RN) and Accredited Health Care Fraud Investigator (AHFI) with ten years of experience in healthcare fraud.

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