Visualize: Insights that power innovation

Visualize: Insights that power innovation

Insurance fraud detection in action: Identifying suspicious medical billing during the COVID-19 crisis

By Jim Hulett  |  June 9, 2020

The COVID-19 pandemic has been a time of selfless dedication and sacrifice from so many of our nation’s medical professionals. But with health care and medical services rapidly evolving to address a changing environment, the pandemic has also given unscrupulous providers opportunities to capitalize on this crisis to commit medical billing fraud, waste, and abuse.

Insurers are no strangers to the high cost of this type of fraud. In 2016, for example, 46 percent of provider fraud cases were attributed to fraudulent billing and billing for unnecessary services. But, unfortunately, the pandemic is giving rise to a new wave of questionable behavior showing up in insurance claims. In April 2020, Verisk data showed a 14 percent increase in claims linked to providers with suspicious billing practices.

Potential red flags for insurers

Taking a closer look at medical billing helps identify pandemic-related issues that can put patients at risk and negatively impact insurers’ bottom lines. The ISO MedSentry team has identified several COVID-19 medical billing scenarios that may demand more detailed examination from insurers.

Unlisted lab tests

Although some medical offices were testing for COVID-19 early on, there was no specific ICD-10 code for COVID-19 until April 1. Prior to this date, any COVID-19 tests were likely coded as “unlisted laboratory tests.” If you receive claims for a patient who has received both an unlisted laboratory test and a COVID-19 test, it may be cause for scrutiny.

Hands-on therapy charges

As the pandemic spread, many medical providers eliminated in-office visits and began to offer telehealth sessions. While many services are appropriate for telehealth, hands-on therapies such as chiropractors, physical therapists, and massage therapists may not be appropriate for virtual appointments, so billing should be examined.

Unnecessary DME (Durable medical equipment)

Billing for unnecessary durable medical equipment is another potential scam that may be perpetrated during the pandemic response. Insurers should be wary of misleading claims for gloves, facemasks, thermometers, and similar items, especially for patients who have not been tested for COVID-19 or have tested negative.

Elective surgeries during lock down

Beginning in March and April, many states suspended elective procedures for a number of weeks. Claims for elective surgeries that took place during a state’s period of suspension might likely be either errors or fraudulent.

Genetic testing

While there has been some very early research on the relationship between genetic factors and COVID-19 susceptibility and severity, to date there has not been a call from the medical community to conduct such testing in relation to the virus. Such claims may constitute waste, abuse, or fraud.

Unlisted vaccinations

While the United States and other countries work diligently to develop a vaccine for COVID-19, it is unfortunately not available yet. Therefore, coronavirus-related immunization claims should raise concern.

Additional indicators of potential fraud

We’ve been looking for other signs of suspicious behavior, including providers who are billing for a high number of office visits while others in their region have few or none. Similarly, a consistent pattern of increased claims from one provider, while other providers in the area are submitting less claims, may call for further investigation.

ISO MedSentry is already finding COVID-19 related fraud, waste, and abuse

ISO MedSentry has added new fraud models for these COVID-19 specific schemes, and the system is already finding pandemic-related fraud, waste, and abuse in the bills entering the database. Our team is committed to detecting these aberrant practices.

If you’d like to learn more about how ISO MedSentry combines predictive analytics, highly tuned algorithms, and expert clinical review to identify suspicious medical billing during the COVID-19 crisis and beyond, please reach out to me.


Jim Hulett is vice president of product innovation for ISO Claims Solutions. You can contact him at jim.hulett@verisk.com.