As payers adjust their business models to manage the COVID-19 pandemic, they must stay vigilant to new fraud, waste, and abuse (FWA) opportunities that fraudsters and others looking to “cheat the system” will place into action.

More Lenient Authorization Policies  FWA may increase due to the Centers for Medicare & Medicaid Services’ (CMS) recent memorandum to Medicare Advantage and Part D plans, loosening authorization policies. This could give fraudsters the opportunity to exploit the changing guidelines to commit more fraud and abuse.

The Rise of Telehealth  Even with a small amount of data, it has become obvious that telehealth is one area of the healthcare industry that is particularly vulnerable to fraudulent activity. Many health plans’ members are utilizing telehealth to receive care during the pandemic, especially during periods of isolation, but this opens the door for fraudsters to bill for unnecessary services or services not rendered.

Lab Billing  Health plans should be on the lookout for any spikes in lab billing for recently approved testing codes related to coronavirus.  New guidelines and new coding procedures make the environment ripe for FWA related to diagnoses related to coronavirus symptoms.

Healthcare payers need to be aware of an increase in suspicious billings around:

  • COVID-19 tests
  • COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth
  • Removal of prior authorization requirements
  • Waiving prescription refill limits
  • Relaxing restrictions on home or mail delivery of prescription drugs
  • Expanding access to certain telehealth services

There is no telling how the payer industry will continue to change in the next coming months.  In the changing regulatory environment fueled by COVID-19, a true AI FWA system like WhiteHatAI’s Centaur platform is crucial, eliminating the lag of manual updating and adjusting antiquated FWA detection systems which can lead to millions of dollars lost to FWA.