Everyone in the healthcare field is very aware of the ongoing DME billing schemes. The most recent topic in the news has been the intermittent catheters schemes. Catheters are thin, flexible tubes that play a crucial role in managing various urinary and other medical conditions. Intermittent catheterization (IC) is a medical procedure that is a safe and effective way to manage bladder issues. But when these codes are overutilized and inappropriately billed, there is potential for high-cost losses.
What to look for?
Catheters and supplies are billed under HCPCS codes A4351, A4352, A4353 and A4332 and usually have a maximum quantity of 200 per month[1]. There should also be a supporting diagnosis code from the referring physician. Always check your respective plan policies and/or contracts. There are many medical policies and number of units limits that should be reviewed to identify potentially improper billing.
HCFS has you covered
If you are using the HCFS Platform™, we have you covered with both our DME AI models and alerts which include, but are not limited to:
[2666-01] – SUPPORTING DIAGNOSIS MISSING, INTERMITTENT CATHETERS BILLED BY NON-PAR PROVIDERS
[2666-02] – INAPPROPRIATE SERVICES, INTERMITTENT CATHETER SCHEME
[2666-20] – SPIKE IN CLAIM VOLUME FOR INTERMITTENT CATHETERS
[2485-01] – INAPPROPRIATE NUMBER OF UNITS, INTERMITTENT URINARY CATHETERS, KITS AND STERILE LUBRICANT
So, what is next on the DME scheme horizon?
How do you know what to be on the look-out for? You will know by using the HCFS Platform™ to detect and keep pace with the constantly evolving fraud, waste, and abuse schemes that are putting your payment integrity at risk. Designed and validated using known healthcare fraud, waste, and abuse cases, it has superior prediction capability and accuracy. FWA360Leads® combines both our AI and our targeted analytics into one powerful prioritized feed utilizing machine learning.
REFERENCES:
[1] https://oig.hhs.gov/oei/reports/OEI-04-20-00620.pdf
If you have questions or comments you may email us at [email protected].