Data analysis from healthcare AI company spanning nearly two years of telehealth claims indicates high potential for rapidly increasing fraud schemes and provider coding errors in a new telehealth era
Codoxo, a trusted provider of healthcare artificial intelligence solutions for healthcare payers and agencies, has released a new study revealing that among the 41% of provider specialties showing statistically significant increases for telehealth adoption, up to 15 percent of telehealth claims are non-compliant with CMS guidelines. The report, “Fraud Schemes in a Telehealth Era: What Healthcare Payers Should Know,” highlights provider specialties where telehealth modifiers were used but lack accompanying eligible CMS billing codes, which may indicate wasteful, abusive or erroneous practices and warrant immediate investigation.
“With telehealth here to stay, our analysis of telehealth data and guidance for cost avoidance should be useful to health plans as they navigate a new age of virtualized healthcare delivery,” said Saurav Subedi, Director of Data Science at Codoxo. “Before the pandemic, healthcare payers already were under siege, battling fraudulent and other anomalous claims cases. But the rapid adoption of telehealth has triggered an explosion of new novel schemes that can put millions of additional dollars at risk.”
Codoxo’s study was conducted over claims submitted across various geographic regions from September 2019 to July 2021. The study spans multiple lines of business, including Medicare, Medicaid, and commercial. The report features the top 10 CPT/HCPCS codes linked with telehealth modifiers even though they aren’t among codes recommended by CMS. These 10 codes represent 58% of all non-compliant codes found in Codoxo’s analysis.
Within the first three weeks of the WHO declaring the COVID-19 pandemic, telehealth visits skyrocketed 154 percent, according to the Centers for Disease Control and Prevention, compared to the same time period just one year prior. After sharply peaking in April 2020, telehealth has since leveled off, finding a new elevated steady state at approximately 20-times higher than pre-COVID rates, according to Codoxo’s anonymized health plan data.
“Any time we see significant changes in the healthcare industry and radical shifts in billing patterns, bad actors find a way to take advantage of those transitions. The boom in telehealth was no exception,” stated Musheer Ahmed, Codoxo’s Founder and Chief Executive Officer. “But if healthcare payers and government agencies can quickly identify, investigate, stop, and prevent suspicious telehealth activity and incorrect payments, the entire healthcare ecosystem benefits by avoiding massive, unnecessary, and otherwise avoidable costs.”
To access Codoxo’s full report, visit https://www.codoxo.com/fraud-schemes-in-a-telehealth-era/
Codoxo is advancing how payment integrity, fraud, waste, and abuse in the health payer and agency industry is tackled with its disruptive AI technology. To find out more about Codoxo, its Healthcare Integrity Suite of solutions and its Forensic AI Platform, please visit https://www.codoxo.com/forensic-ai-platform.
Codoxo is the premier provider of artificial intelligence-driven applications that help healthcare companies and agencies identify and act to reduce risks from fraud, waste, and abuse. Codoxo’s Healthcare Integrity Suite helps clients reduce risks and costs across network management, clinical care, provider education, payment integrity, and special investigation units. Our software-as-a-service applications are built on our Forensic AI Platform, which uses a patented algorithm to identify problems and suspicious behavior earlier than traditional techniques. Our solutions are HIPAA-compliant and operate in a HITRUST-certified environment. For additional information, visit www.codoxo.com