We all want to stay on top of our health, and regular checkups with a doctor are a great way to do that. But in our quest for early detection, have we fallen into the trap of too much testing? We’ve all heard the saying ‘an ounce of prevention is worth a pound of cure’, but when do the ounces outweigh the pounds? While preventive screenings are crucial for catching health issues early there is potential for over screening and over billing.
What to look for?
Medicare, and other payors, cover many preventive services to keep patients healthy. Preventive services can help find health problems early, when treatment works best, and can help keep patients from getting certain diseases [1]. Tests and screenings are available for a vast number of medical conditions and reasons – from annual wellness visits to depression to bone mass measurements to glaucoma to lung and other cancers and everything in between. These tests give healthcare providers the tools necessary to assist patients in being able to stay on top of their health, but they can also be a gateway to inappropriate billing and overbilling.
With such a vast range of screenings available, payors should review their current medical policies and claim edits to ensure they are staying on top of new and existing medical screening coverages and guidelines.
1) Look for providers billing for new services that weren’t previously billed for.
2) Look for providers billing with similar or exact patterns of services for a majority of their patients.
HCFS has you covered!
A new or changed billing pattern can be difficult to detect initially, creating a higher risk for exposure to improperly paid claims. If you’re using the HCFSPlatform™, we have you covered. Our Artificial Intelligence (AI) models can help identify changes in billing, spikes in billing and other anomalous billing patterns. Additionally, we have many specific Alerts set up to flag screenings services whether it is for an inappropriate number of services or when a supporting diagnosis isn’t found in the patient’s medical history. In addition to those, HCFS recently added these new screenings alert:
[2688-01] – INAPPROPRIATE NUMBER OF SERVICES, GLAUCOMA SCREENING
[2689-01] – INAPPROPRIATE NUMBER OF SERVICES, HEPATITIS C ANTIBODY SCREENING
[2691-01] – SUPPORTING DIAGNOSIS MISSING, LUNG CANCER SCREENING WITH LOW DOSE COMPUTED TOMOGRAPHY (LDCT)
[2693-01] – INAPPROPRIATE NUMBER OF SERVICES, BONE MASS MEASUREMENT
[2694-01] – INAPPROPRIATE NUMBER OF SERVICES, ULTRASOUND SCREENING FOR ABDOMINAL AORTIC ANEURYSM (AAA)
[2696-01] – INAPPROPRIATE NUMBER OF SERVICES, DEPRESSION SCREENING
[1] https://www.cms.gov/medicare/coverage/preventive-services-coverage
If you have questions or comments you may email us at [email protected].