NHCAA held their Annual Training Conference (ATC) last week in San Diego, giving healthcare anti-fraud professionals the opportunity to join, connect and network with industry friends (new and old). It was a week full of opportunities to learn new and exciting ways to further fraud fighting capabilities. Healthcare Fraud Shield (HCFS) joined the conversation when Executive Vice President Karen Weintraub and Molina Healthcare Director Kristin Griego presented AI-Assisted Record Review for Specialty-Driven Fraud Schemes. During this session they shared practical strategies for applying AI using RecordPlus and analytics to medical record reviews.
What to Look For
If you missed it because you were attending a different concurrent session or if you missed attending ATC altogether, here are some of the areas that were highlighted:
- Laboratory panel unbundling and excessive testing: Watch for unusually high units of CPT 87798, Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified. Also keep an eye on multiple PCR codes for the same testing purpose and/or broad panels routinely billed without patient-specific rationale. Compare the original orders, the assay performed, specimens, and results to determine whether the tests were distinct and supported by the patient’s clinical circumstances.
- Unsupported high-level E/M services: Look for repeated billing of high-level Evaluation and Management codes (99215) and verify that the record supports high medical decision-making or qualifying time. Look for records containing copied history or generic “high-complexity” language. For add-on code G2211, examine the time, intensity, and practice expense related to the ongoing care relationship. For E/Ms billed with a procedure, be sure to identify the significant, separately identifiable work represented by any used modifier. On another note, CMS is introducing a new modifier, modifier B1 to be used instead of G2211 effective January 1, 2027.
- Time inflation and potentially impossible workdays: For E/M services levels selected by time, the documented minutes must be reconciled across the rendering clinician’s entire day. This is how 30 encounters of 40 minutes each adds up to 20 hours of the provider’s day – before any other work is counted. Other areas to watch are double-counted minutes, clinical staff time included as clinician time, or time already attributed to separately billed services.
- Cloned or superficially altered documentation: Recording cloning is a major concern. Look for identical narratives across patients while also accounting for expected template language. Also pay attention to smaller edits to repeated text, and similar clinical descriptions expressed using different words. Comparing patient-specific findings, decisions, and treatment responses will determine whether each record supports the encounters billed for.
- Unsupported residential treatment days or levels of care: Watch for billed days that conflict with attendance records. Treatment plans should contain measurable goals and daily notes (including extended stays) should be tied to the specific member and support for the level of care. Reconcile claims billed with reassessments and progress notes. Review staffing schedules, clinician qualifications, and discharge plans to assess what care was delivered, who delivered it and why it remained necessary.
HCFS has you Covered
As AI continues to grow in the FWA space, fraud schemes grow more sophisticated. Technology can help prioritize leads, extract relevant information, and reveal discrepancies. Fighting AI with AI is emerging, but it will never replace the importance of human-in-the-lead, or human-in the-loop. Analytics can flag documentation similarities that serve as leads for further review; however, conclusions require context and professional judgment. Record reviews remain integral in combating improper billing. The HCFSPlatform™ supports this work using both AI and targeted alerts helping payers identify unusual billing trends, prioritize outlier activity, and focus investigative resources on areas with the greatest potential impact. Want to learn more about the HCFSPlatform? You can contact us at [email protected] If you have other questions or comments, you can contact us at [email protected].
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