Medical provider fraud, waste, and abuse— which have largely eluded most insurers—is an insidious, often unseen, problem that can damage insurers’ margins. This unnecessary spend is happening at a time when medical costs overall are on the rise. From 2008 to 2017, the average cost per paid bodily injury liability claim increased 31 percent, and personal injury protection (PIP) claims increased by 26 percent. In light of these increases, it’s more important than ever to detect where the abuse is occurring.
For any system to uncover suspect billing, it must continuously monitor practices that are wasteful or fraudulent. Back in 2016, Verisk’s ISO MedSentry® system began keeping a watch on a procedure known as P-Stim, an electrical nerve stimulator that is not always covered by CMS or private insurance. Some medical offices had been billing for this procedure with medical codes that do not correspond to P-Stim treatment which can lead to higher reimbursement.
On January 4, 2021, the U.S. Department of Justice announced a settlement in which three providers agreed to pay the United States and the State of Tennessee $1.72 million dollars as a result of violations of the False Claims Act. In the announcement, the use of P-Stim was the driving issue.
Based on the facts and settlement agreement in the recent DOJ case, ISO MedSentry is closely monitoring billing procedures and codes related to P-Stim treatments in our ongoing endeavor to help combat suspicious provider billing. For more information about ISO MedSentry, please feel free to reach out to me.