Medical claims charges that were “red flags” a week ago suggesting possible criminal activity are suddenly acceptable today, putting stress on systems and organizations that have difficulty adjusting in a changing regulatory landscape.
Medicare has temporarily expanded its coverage of telehealth services to respond to the COVID-19 crisis. The Center for Medicare and Medicaid Services (CMS) has temporarily modified and eased their guidelines while expanding their acceptance of telehealth reimbursement.
During the Covid-19 pandemic, Medicare beneficiaries can temporarily use telehealth services for common office visits, mental health counseling, and preventive health screenings. This will help ensure Medicare patients have access to appropriate levels of healthcare from their home without putting themselves and others at risk via visits to doctor’s offices and/or hospitals.
Medical claims systems and fraud, waste and abuse (FWA) solutions must quickly update and apply these important reimbursement regulation changes. Under previous rules and guidelines, the waiver of cost-sharing responsibilities or copayments would be considered a kickback in the eyes of the Office of Inspector General. FWA Systems should have the ability to recognize new regulations and guideline modifications and accept or deny claims based on these new rules or risk bogging down the medical claims industry with erroneous denials, producing costly and time-consuming resubmissions.
Medical claims and FWA systems must also quickly adjust provider data base information. Many providers that previously did not participate in Medicare can now, in this extraordinary time, provide and be reimbursed for treatment services.
Sharecare Payment Interity’s technical personnel are making sure that, in this crucial moment in time, the uniquely architected Centaur technology instantly “pivots” as designed to all of these regulatory and payment environment changes and identifies true suspicious provider and claims activity.