FWA Briefs

Dr. Steve Nesnidal of Context 4 Healthcare, Inc. presented at the 2023 NHCAA Annual Training Conference on Overutilized High-level Drug Testing, focused on Small Fees with Large Overpayments. Dr. Nesnidal goes into depth about specific cases where aberrant providers intentionally billed a higher amount of the higher-level codes.

The Centers for Medicare & Medicaid Services (CMS) recently released new guidance that may affect certain providers wanting to obtain an NPI if they don’t already have one. These guidelines are important for you and your health plan to have protection against fraud, waste, or abuse (FWA) in your claims.

On May 19, 2021, the Medicare Payment Advisory Commission (MedPac) provided feedback to Congress regarding their opinions on the effectiveness of the overwhelming 200 healthcare policy changes that Congress and CMS instituted during the interval of January through July 2020, in response to the coronavirus public health emergency. Aside from the obvious and necessary benefits of these changes in response to the pandemic, MedPac raises concerns about the detrimental impact in the realm of fraud in healthcare: “…not all actors in the healthcare system are well-intentioned”.

During the pandemic, healthcare claim fraud prevails as new fraud schemes develop and adapt to the changes in healthcare guidelines enacted, so providers can continue to treat patients. Two major areas of FWA expansion during the pandemic include Telehealth and COVID-19-related laboratory testing add-on services.

Pfizer and Moderna Covid vaccine codes receive effective dates, AstraZeneca vaccine assigned procedure codes but not yet effective.