August AI Alert 2024 - Codoxo (original) (raw)
The Hidden Costs of Overlapping or Excessive Monthly Services
Monthly management of patient care
Monitoring and coordinating care for patients with chronic conditions, such as heart disease or kidney disease, may be managed monthly by their primary care or a single specialist, such an internal medicine, cardiology or endocrinology provider. The Centers for Medicare and Medicaid Services [CMS] define specific procedure codes as Chronic Care Management [CCM] services to assist with management of the patient’s overall care. Additionally, there are numerous other procedure codes for services allowable one per month or up-to-30 days related to end-stage renal disease, cardiac monitoring, and behavioral health.
Many health plans routinely review per diem / per day procedure codes or have edits in place to identify potential utilization issues for a patient. Some health plans may have edits in place that apply procedure limits for annual or lifetime benefits; however, some monthly services may be overlooked or easily bypassed when a different provider submits an overlapping claim.
Waste and Abuse for Monthly Procedure Codes
While reviewing detection models and providers across various peer groups in our partner plans, Codoxo’s Customer Success Team noted numerous patients with overlapping monthly services. We noted that many of the overlapping services were billed by different providers within the same peer group and some were billed by the same provider. Of interest, another strong signal included patient sharing patterns across the different providers within the same peer group.
One example of an overlapping scenario included monthly services for end-stage renal disease management where one endocrinology provider billed CPT 90960 and a different provider billed CPT 90961 for the same patient and different date of service, yet the same month of service, repeatedly. The identification and discussion of these claim scenarios prompted review by the partner, investigation, recovery of overpayments or provider education and monitoring, when appropriate.
To assist readers of this month’s AI Alert, Codoxo’s Customer Success Team created a table of procedure codes, which is available as an addendum. The table outlines the specific frequency [monthly or up-to-30 days] as well as the expected peer group for the service, the procedure code, and the description. This table can be used to compile and analyze groups of codes at a health plan to assess whether patients are receiving monthly services beyond the expected limits.
How can Fraud Scope help your health plan or health agency identify overlapping monthly services?
Fraud Scope’s pattern-based detection models, such as Suspicious Trends and Time Behavior can identify the same provider with overlapping monthly services for a specific procedure code. The data collection, analysis by the AI, and charting options of the results allow the user to identify the patients that display overlapping or excessive services within the reporting period.
Fraud Scope’s Query Builder empowers users to explore healthcare intelligence at the line, claim, or aggregate levels and to define criteria specific to their assessment. Codoxo’s partners can apply groups of similar procedure codes by expected peer group or code description from the addendum to build line level queries to identify patients whose utilization history demonstrates overlapping or excessive monthly services by the same or different providers.
Fraud Scope’s Association Graph identifies claim relationships between providers using common addresses or common patients. After a user identifies a provider with overlapping or excessive monthly services, it may be prudent to determine if that specialist has a high-volume of common patients with other providers in the same specialty, such as endocrinology or cardiology, which could be a signal for patient sharing. The Association Graph results display provider identifiers [NPI, Tax IDs], risk scores, and practice intelligence for the user to assess, which includes hyperlinks to the shared claims data. The shared claims data displays all the claim line details and charting options so the user can assess whether potential overlapping or excessive monthly services exist between the two providers for multiple patients.
References:
Centers for Medicare and Medicaid Services
AMA/CPT procedure codes
https://www.ama-assn.org/amaone/cpt-current-procedural-terminology