Comparative Analytics: Take a Fresh Approach to Eye Care Fraud Prevention

A significant number of cases of eye care fraud have been reported in the news this year—including the eye care provider in Georgia convicted of collecting more than $1 million from Medicare and Medicaid for services she never performed. Then there was the eye doctor in Florida convicted of 67 crimes between 2008 and 2013, as well as the Kentucky-based optician also charged for billing for services never provided.

Of course, you do your best to keep your claims clean. But don’t think that just because your practice never intends fraud that you’re safe from the wrath of audit agencies. In fact, conventional wisdom is full of misconceptions regarding fraud and “red flags,” says audit compliance instructor Jeffrey Restuccio in his fraud prevention webinar with ProfEdOnDemand. As part of his three-webinar ophthalmology coding and compliance series during the 2019 Coding Updates Virtual Boot Camp, Restuccio teaches a new way to approach fraud using proven techniques and an action plan to ensure compliance—for even the most well-intentioned practices out there.

Watch for 3 Unexpected Fraud ‘Habits’

Again, if you think having good intentions means you’re compliance-ready, well … unfortunately, that’s not the case.

The proper (and obvious) steps to take to avoid fraud include: never billing for services not rendered, always billing the correct patient, and never making up a patient’s name. However, there are also many common, less obvious mistakes you and your physicians may be making that put the practice at risk without your knowing it. These mistakes—call them bad habits—say analysts at HealthLeaders, include the following:

  1. The expired license: In this case, your claims are clean, and the physician is licensed to offer the services rendered—but that license has lapsed. Even if the license is expired by only a few days, Medicare could very well consider the claim fraudulent.

Solution: To combat this issue, have all physicians in your practice renew their licenses well before they’re set to expire.

  1. Lack of supervision: Several CPT(R) and ICD-10-CM codes specify what kind of supervision is required to bill for a code. Payers may give extra scrutiny to procedures requiring supervision and will be quick to call “fraud” if the requirements aren’t met.

Solution: Be sure physicians (and you) clearly understand what they must do and where they must be to properly supervise according to Medicare and private payer rules.

  1. The assumption: We can’t stress enough the fact that, to bill for a procedure, you must have evidence of the procedure and of its medical necessity in the documentation. Assuming that something was done will throw up a hundred red flags, at least, for payers.

Solution: Always bill only for what’s in the record, and ask for needed clarification from eye care providers.

Fraud Detection in the Blink of an Eye

Now you know that (unintentionally) committing fraud is a lot easier than you think. Time to learn how to actively combat fraud—because the penalties for not being proactive are steep. Although the big-news-story examples cited above involved physicians who intentionally committed fraud, their multiple-year prison sentences are nothing to take lightly.

Instead of hoping for the best, take action. Specifically, act on data gleaned from comparative analytics.

With this strategy, you’re examining elements such as: reimbursement data, utilization of evaluation and management (E/M) codes, and analysis of office visits and diagnostic procedures. You’ll start to see patterns in your practice. And then you can compare your coding and billing patterns to those of other practices. In the end, you have a clear picture of your practice’s procedures, and you’re in a much better position to catch anomalies before they become noncompliant habits and audit findings.

See Clearly With the Right Data

Whether comparative analytics is new or familiar to you, it’s vital that you understand how to use it wisely and proactively in this age of eye care fraud scrutiny, affirms Restuccio. In his fraud prevention webinar, he teaches attendees to develop an action plan and documentation checklist that, when paired the results of a comparison analysis, can keep the angry eye of audit agencies far away.

To join the conference or see a replay, order a DVD or transcript, or read more

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