FWA Insights: Q&A with the SIU

While prepay claim editing systems continue to grow more advanced, they can’t prevent every fraud, waste, and abuse (FWA) scheme from slipping through the cracks. That’s why a high-performing special investigations unit (SIU) must be powered by both human expertise and advanced analytics to sift through mountains of data and identify aberrant trends.

Here, we conduct a Q&A with some of Cotiviti’s own credentialed investigators to break down complex questions related to skin grafts and substitutes, a growing area of FWA capturing attention nationwide.

What are the top billed codes for skin substitutes that can be used for data mining purposes?

Most of the amniotic allograft HCPCS codes are used to identify name brands. The codes recently investigated by Cotiviti’s SIU include: Q4173, Q4262, Q4205, Q4250, Q4248, Q4234, Q4205.

Should invoices for skin substitute products be requested when requesting medical records?

Although not required, invoices are helpful in confirming the actual product purchased by the provider and the amount paid versus the amount billed. In various cases investigated by our SIU, the amount the providers were billing health plans greatly exceeded what the cost of the actual item was. In fact, we recently had one review where the provider was billing 2500% of what it cost them to procure the item, because several health plans and Medicare didn’t have a true fee schedule for the skin substitutes and were paying a percentage of what was actually billed.

Have you noticed fraud specifically concerning the waste modifier (JW) with skin graft codes?

The JW modifier has not specifically been a recent issue. The majority of recent cases have involved a low number of members receiving a high number of skin substitutes, mainly amniotic allografts. The allograft and number of units have been the concern along with the number of services per member.

When the JW modifier is used, the claim line with this modifier should have a dollar value assigned per the health plan’s directions. CMS Article A55932 offers guidance pertaining to this question and potential billing scenarios with this modifier usage.

Have you heard of providers charting that they “packed the wound” with the excess instead of wasting it?

Yes, this is something that our medical review team has seen when reviewing records related to skin substitutes. We have seen providers bill for three times the amount of skin substitute (larger than the wound) while claiming they used all of the membrane on the patient.

For allografts, what is a reasonable changing frequency of wound care?

Allografts are a thin membrane that is permanently applied and is not changed. Allografts can be reapplied at certain intervals to provide a scaffold for tissue regeneration. Frequency of reapplication depends on the severity of the wound and would depend on the wound management plan developed by the provider dealing with the patient and their conditions.

Is there a medical reason that a provider would use an amniotic allograft over something that might be a less expensive option?

Amniotic allografts typically have a shorter healing time and less risk for infection than other grafts, such as those derived from animal tissue (xenografts) or those derived from cadaver tissue or a type of synthetic tissue. It also depends on what substance the provider prefers to use in the patients’ treatment or what is readily available to the provider at the time of service. We have seen providers change types of skin substitute throughout the treatment.

Can a nurse practitioner bill for skin graft services?

A nurse practitioner may perform these services under the supervising physician.

Do you see this issue with excessive skin substitutes in the facility setting as well?

Skin substitutes may also be applied in skilled nursing facilities (SNF), so this can be a concern.

Would you be concerned if skin substitutes were billed for Medicare patients?

FWA involving skin substitutes can occur in any line of business, making it important to check for outliers and payment spikes for all providers. Although services may be covered and paid for by Medicare, they should be supported by proper medical record documentation and performed according to CMS guidelines. Most health plans have contracts containing language regarding claim denials when FWA is suspected. Reach out to your legal department with specific questions on how your organization communicates these denials to providers.

Is it unusual to see skin substitutes billed in the home?

No, this is not unusual. If the patient is homebound and suffering from bed sores or not able to travel due to diabetic foot ulcers, they may need wound care in the home.

What are suggested next steps if you've identified a provider that is an outlier for skin substitute codes?

A prepay review should be considered for the skin substitute codes. A sample of medical records should be requested to perform a postpay review to confirm that services were properly performed and documented by the provider. We recommend a postpay review to recoup inappropriate payments along with a concurrent prepayment review concurrently to stop future potentially inappropriate payments.

Have you seen any upticks in Q4159 (affinity) billing for podiatrists?

We are seeing different HCPCS utilized rather than the same codes used again and again by all providers. This is yet another reason it is difficult to identify these schemes.

Why might a dentist be billing Q4205 (membrane graft or membrane wrap)?

There are different types of grafts that are used in dentistry to repair the tissue inside the mouth and gums. It is important to ensure the provider is billing the proper allograft per the service performed.

What are some other recent trends you’re seeing in the SIU?

Other trends we’re seeing include FWA in durable medical equipment (DME), drop-shipping schemes, behavioral health, laboratory (including urine drug screens and oral fluid testing), excessive dental restorations (including crowns and fillings), and home health.

Many of these questions posed to Cotiviti’s SIU came directly from the audience during our recent webinar, Uncovering hidden FWA schemes, presented by Cotiviti and the National Health Care Anti-Fraud Association (NHCAA).

Watch the full webinar as we break down recent case studies related to skin substitute schemes. You’ll learn:

• Which FWA schemes are most likely to evade standard claims editing
• How to uncover behavioral patterns using both prepay and postpay review
• Best practices to prevent abuse and support proactive, data-driven SIU decisions