Restarting Payment Integrity During and After Pandemic
The past few months have seen dramatic changes as the U.S. was forced to quickly prepare, mitigate and respond to the COVID-19 pandemic. These changes were necessary to provide healthcare access for all who need it and capacity to properly care for those affected from this contagious virus.
Though initial efforts were focused almost solely on increasing hospital capacity, it quickly
became clear that payment integrity (PI) and fraud, waste and abuse (FWA) activities are vital to
assure the financial foundation of the U.S. healthcare system.
Thankfully, initial projections of COVID-19 patient volumes have not yet come to fruition and,
outside of key metropolitan areas, most providers have not seen patient volume increases.
In fact, to date the majority of COVID-19 cases have centered on a handful of U.S. states so
a one-size-fits-all approach to PI and FWA activities doesn’t make sense. Additionally, many
states have begun to relax stay-at-home orders and reopen businesses, though the federal
public health emergency continues.
Importance of PI and FWA Activities
During the ongoing emergency period and afterwards, there may be an increase in inaccurate
coding and billing due to ongoing stress on the staff and systems, and confusion around new
ICD-10, CPT and HCPCS codes. Increased FWA vulnerability due to the relaxation of certain
rules, regulations and other requirements may also occur.
At the same time, our economy is reeling from this crisis with high and rising levels of
unemployment and greater dependence on publicly administered healthcare programs while
tax revenues supporting those programs dwindle. PI and FWA deterrence can help offset
some of those dynamics and simultaneously, ensure appropriate high quality care.
For health plans that changed, limited or stopped PI and FWA activities, it is critical to ensure
a coordinated thoughtful restart. We recommend that states and payers resume normal PI and
FWA activities in areas and providers with low numbers of COVID-19 patients.
When to Restart
Thirty-six governors (and the District of Columbia) issued moratoriums on elective procedures.
If elective procedures are resuming, not only consider that as a strong indicator for restarting
PI and FWA activities, but also think of it as a necessary trigger given that healthcare
consumption may vigorously resume due to pent up demand.
The past few months have seen dramatic changes as the U.S. was forced
to quickly prepare, mitigate and respond to the COVID-19 pandemic. These
changes were necessary to provide healthcare access for all who need it and
capacity to properly care for those affected from this contagious virus.