Updated on: June 11, 2020

Reexamining Internal Compliance Plans as Relaxed Regulations Recede amid COVID-19 Mitigation

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Original story posted on: June 8, 2020

While we continue to remain amid a pandemic, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has not skipped a beat in pressing forward with their plan for addressing potentially fraudulent activity associated with COVID 19 billing. 

As the coronavirus pandemic treks on, the OIG has not waivered off course in constructing a plan for addressing the newly created landscape of COVID-19 billing – and, potentially, fraudulent activity.

Once the president announced that third-party payors would cover COVID-19-related care, it set the stage for confusion, fraud, and ultimately, erroneous data, if the right measures are not put in place to accurately monitor the coding and billing of COVID-19 claims. Then there were the opportunists, taking advantage of the elderly in conducting questionnaires for so-called “COVID-19 testing” in an attempt to collect Medicare beneficiary information to then sell on the black market for identity theft. We can expect a myriad of fraudulent schemes to emerge, exploiting the pandemic, and, unfortunately, creating hurdles for all to overcome.  

In 2008, President Barack Obama formed the Financial Fraud Enforcement Task Force (FFETF), designed to investigate and prosecute financial crimes and violations. The FFETF continues to monitor and pursue a wide range of fraudulent activities. Keeping with the FFETF intention, the current U.S. Attorney General gave the directive to appoint a Coronavirus Fraud Coordinator to address all financial and legal matters related to COVID-19. A hotline and website are in place for reporting fraudulent activity associated with the pandemic. 



Unlike other OIG-related causes, this pandemic has created challenges that have not been previously considered when evaluating fraudulent activity. The new environment has increased the risk of fraud and the need for government as well as care providers to act swiftly. A decision such as this, made without the luxury of long-range planning, affords tremendous risk for mistakes, scams, and, unfortunately, in some cases, malicious intent.

Healthcare organizations have taken a financial hit, to put it mildly, with the cancellation of elective surgeries and lack of offshore coding resources; in some cases, such organizations were forced to abruptly bring operations to a halt when stay-at-home orders were mandated. Additionally, third-party entities may not have been adequately vetted due to the time constraints in generating claims. Plus, the coding and billing guidelines for COVID-19 were and continue to be regularly updated. Due to financial constraints, coders may have been furloughed, laid off, or even let go during this time, leaving a void for COVID-19 coding and billing education. Simply put, preventive functions may be overlooked as other areas require attention to adapt to changes. Healthcare organizations are seeing the need to shift gears and evaluate current compliance efforts to ensure that proper measures are being taken for COVID-19.     

The first line of defense in fraud prevention is implementing a compliance plan now to avoid risk later. The following are primary areas of consideration, along with baseline actions to take in support of the implementation of real-time processes that can significantly help to identify areas of concern.

  • Construct a compliance plan addressing the specifics of COVID-19 coding and billing ─ include your compliance department from the onset for collaborative and thoughtful planning.
  • Develop a pre-bill check and balance process to ensure accurate COVID-19 ICD-10-CM and CPT® code assignment.
  • Ensure designated staff is well-informed regarding the various COVID-19 waivers related to their organization.
  • Explore the opportunity for electronic health records to implement an edit allowing all COVID claims to have a pre-bill review. This provides correction and targeted education prior to claim submission.

These are key considerations for safeguarding an organization and mitigating risk, though the many layers of detail to be taken into account and verified for comprehensive protection against fraudulent activity should not be overlooked.

COVID-19 has had a far-reaching effect on healthcare, leaving many revenue cycle departments confused over guidelines and unclear on the appropriate use of codes, as well as the specificity needed with physician documentation. 

Unfortunately, chaos typically follows confusion. Nevertheless, this is an area that organizations cannot neglect, nor can they afford to miss the mark. The current administration has funneled a tremendous amount of money into healthcare systems. It will not be long before they take steps to ensure that the funds were appropriated as intended.

Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays.

Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

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