How to identify and prevent COVID-19 health care fraud

While health care fraud is an ongoing concern, COVID-19 has precipitated a rise in the number of cases and the ways in which fraud is being perpetuated.

“Two years into the pandemic, we’ve learned a lot of lessons about health care fraud in a pandemic,” says Latrisha Oswald, MSFS, AHFI, CFE, Director of Financial Investigations and Provider Review, Highmark Blue Cross Blue Shield. “It is critical that insured members and their employers be mindful when seeking care and report potential fraud, abuse and waste. If you suspect something, report it to your insurance provider so it can be investigated to identify possible patterns of abuse.”

Smart Business spoke with Oswald about how employers can help employees avoid being victims of fraud and how to report suspicious activity.

What trends have you seen regarding COVID-19 health care fraud?

The most immediate fraud was in personal protective equipment, with fraudulent masks and gloves sent to hospitals. Then it moved to abuse in coding and billing of associated services with tests and vaccines. One of the biggest areas was in drive-through pop-up testing sites, with providers charging for high-level office visits — which generally include an exam of 30 to 60 minutes with a physician — even though people weren’t leaving their cars.

Pop-up labs, which tend to stay out of network, were charging up to $1,800 for tests, when the average is $50 to $100. Members should review their Explanation of Benefits, question suspicious activity and look for unexpected charges, or charges higher than warranted for services received.

What should employers understand about COVID-related health care coverage?

Fraud and abuse drive up costs for everyone; for the fully insured, it results in higher premiums and higher employer contributions, and for the self-insured, it means fewer dollars are available to pay claims. Educate employees to use providers in their network, who are known to them, and steer clear of pop-up sites that may only be in it for profit.

Encourage employees to take the time to review their Explanation of Benefits and look at what is being billed vs. what they expected to be billed. Be alert for unexpected charges, especially in office visits for testing or vaccines. Insurers don’t expect members to know everything about medical coding for health care billing, so if something seems suspect, ask.

Employers should also educate employees to be aware of advertisements for unauthorized vaccines or medications to treat the virus, ads offering treatments that are ineffective and of scams, including someone offering free test kits in exchange for insurance information. An insurer will not contact members offering free services or medication.

In addition, be aware that COVID testing required by an employer in most cases is not a covered benefit and must be paid for by the employer or employee. And while insurers are now required to cover over-the-counter testing, at a cost of generally $12 per test, be mindful of that average when purchasing tests and that insurance will only cover up to eight tests per member per month. The coverage of over-the-counter testing does not extend to employment required testing.

Why and how should members report suspect charges?

Reporting allows the insurer to explain what a member is seeing. The insurer can look into the charges and either ensure they are valid or begin an investigation if they are suspicious. It may just be a one-off billing error, but in some cases, a report can be a starting point to uncover inflated billing across the patient base of a provider.

Reporting can be done anonymously through a hotline, email, an electronic form or a physical letter. If you suspect something, say something. Insurers take protecting privacy very seriously and members should have no fear of retaliation.

It’s critical that employers understand what is being billed on their insurance plan and that consistent messaging to employees is ongoing. Employees need to understand their Explanation of Benefits and know how to report it if they have been charged for services they didn’t receive or if charges seem inflated. ●

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Latrisha Oswald

Director of Financial Investigations and Provider Review
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