COVID-19 and Healthcare Claims

While it’s still too early to get precise numbers, it’s clear that fraud, waste, and abuse (FWA) costs have skyrocketed during the COVID-19 era. These charges are contributing to the increase of health care costs, making it harder for healthcare payers to provide affordable plans and options for their members, 

In order to keep out-of-pocket costs down and prevent sharp rate increases, a strong payment integrity program is more important than ever before. Let’s take a look at the fraud, waste, and abuse problem in the COVID era and the effects on health care payers. 

COVID Fraud, Waste, and Abuse Costs

One in six medical claims contains at least one error, according to most estimates. Fraud, waste, and abuse costs have been a long-term, increasing issue across medical and pharmaceutical claims.

Fraud, Waste, and Abuse Definitions

Fraud: Deliberate schemes to charge higher, unearned and unauthorized rates using intentional deception or billing for services or procedures that never took place. 

Waste: Erroneous charges, such as medical billing and coding errors. These might be isolated events, such as miskeyed codes or misunderstood handwriting, or chronic issues caused by a misunderstanding of proper coding procedures.

Abuse: Abuse refers to systematic overcharges contradictory to accepted medical or business practices, such as providing and billing for medically unnecessary services or coding a higher level of service than the provider actually provided.

It’s become easier to ferret out charges like this through the advancement of data analytics. Payment integrity has become a major focus of many healthcare payers. However, the rapid changes taking place during the COVID-19 public health emergency have challenged payment integrity professionals. 

  • Changes and waivers to policies and procedures to streamline care and reduce strain on healthcare systems.
  • Rapid increase in telehealth usage
  • Waivers or suspensions of regulations such as Stark’s Law
  • Excessive COVID-19 diagnosis in situations with enhanced payment levels

As more pandemic-era claims have been processed, patterns have emerged showing a clear increase in FWA charges at the expense of healthcare payers, plan members, employers, and other stakeholders. Medical billing and coding specialists have had to master a plethora of new codes and how to apply them, especially with the expansion of telehealth. Administrative staff have to do more than ever before, often working extra hours and working from home with less support than they’re accustomed to. It’s no wonder that FWA charges have increased so dramatically. 

How do we rein in these charges and prevent future overpayments? 

That’s where data comes in. 

Data-Driven Payment Integrity

While policies and procedures were streamlined during the COVID-19 pandemic, paperwork wasn’t. Analyzing medical claims for FWA can involve tremendous amounts of paperwork to understand the case and the context in which providers billed for services and procedures. 

Artificial Intelligence, machine learning, and automated workflows have tremendous potential in addressing these issues, but these can be expensive and time-consuming to develop. That’s why many healthcare payers are choosing to partner with an established payment integrity solution that can provide scalable, effective solutions. 

A Scalable Solution

Alaffia Health’s next-generation AI platform provides these solutions with a fusion of human expertise and machine speed and accuracy. Our platform identifies the high-cost claims most likely to contain FWA charges, requests the supporting paperwork necessary to validate those claims, and then kicks it to a human payment integrity expert for review of the claim and supporting documentation. Using AI not only means reviews of more claims; it means human analysts spend more time on claims with a higher chance of overpayment, driving efficiency to stratospheric heights. 

Our AI platform utilizes machine learning to get smarter with each claim it reviews. The sheer volume of COVID-19 related claims makes our AI better at recognizing potential FWA charges in these claims. 

Best of all, Alaffia’s a turnkey solution. We plug into your existing processes and workflows and get to work, generating savings for you immediately. And we get paid for production; our fees are contingent on how much we save our partners. 

As we settle into the new normal, fraud, waste, and abuse costs aren’t going away. Healthcare payers must enact robust payment integrity solutions to control costs and continue to provide care for their members at reasonable rates. Alaffia Health is the solution. Learn more today!