by Carlyn Hoffman, AHFI, Sr. Investigator
Is Healthcare Getting Back to “Normal”?
With the expiry of the Covid-19 Public Health Emergency (PHE) as of May 11, 2023 at 11:59pm, healthcare is slowly getting back to “normal”. With rules and regulations ever shifting, it can be hard to determine what’s the new normal, and detecting Fraud Waste and Abuse (FWA) can be a moving target.
One silver lining of the PHE seems to have been the expansion of telehealth services and medications for Opioid Use Disorder (OUD) and Medication Assisted Treatment (MAT). The Centers for Medicare & Medicaid Services (CMS) published a press release[1] touting a study [2] published on March 29, 2023 in JAMA Psychiatry. The study analyzed a pre-pandemic cohort and a pandemic cohort of Medicare beneficiaries and found that Medicare beneficiaries who received telehealth services for OUD had a 33% lower risk of a fatal drug overdose.
Wilson Compton, M.D., M.P.E, deputy director of the National Institute on Drug Abuse and senior author of the study concluded “Research continues to indicate that expanded access to telehealth is a safe, effective, and possibly even lifesaving tool for caring for people with opioid use disorder, which may have a longer-term positive impact if continued.” On May 10, 2023, the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a temporary rule extending the COVID-19 telemedicine flexibilities for MAT. New practitioner-patient relationships may be established via telemedicine through November 11, 2023, and patient-practitioner relationships that have already been established or will be established before November 11, 2023 may continue via telemedicine for an additional year through November 11, 2024. SAMSHA and the DEA are developing a permanent rule that would further extend these flexibilities. It’s encouraging to see flexibilities that broke down barriers to access to care extended.
MAT is a particularly important topic as the opioid crisis continues to claim over 50,000 lives in the United States each year. Unfortunately, as we open up regulations and remove barriers to treatment, we also open ourselves up to potential FWA. Mark Starinsky, AHFI, CFE, CHC, SE and Integrity Advantage’s own Carlyn Hoffman, AHFI discussed this conundrum in Shift Technology’s January 31, 2023 webinar “How Are Health Plans Playing a Part in the Behavioral Health Crisis?” available on demand at https://www.shift-technology.com/resources/videos/how-are-health-plans-playing-a-part-in-the-behavioral-health-crisis. In addition to MAT, the presentation also discusses coding and policy changes, telemedicine trends brought about by the PHE, and emerging schemes such as misuse of added complexity code 90785, improper billing of Applied Behavior Analysis (ABA) codes, and billing for impossible days.
As we move forward from the end of the PHE, the lessons we learned from the flexibilities established to handle the PHE will help ensure patients receive the highest quality of care with the fewest accessibility issues. It can be challenging to keep up with coding developments and new rules and regulations across different specialties, states, and lines of business. If you need help untangling these changes, Integrity Advantage is here to help! Our experience providing consulting, investigation, medical review and training support to plans across the country gives our clients a tremendous advantage. We take our role as trusted advisors very seriously, providing objective perspectives and offering solutions for real challenges faced by the healthcare payment integrity industry.
[1] https://www.cms.gov/newsroom/press-releases/increased-use-telehealth-services-and-medications-opioid-use-disorder-during-covid-19-pandemic
[2] https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2802946?guestAccessKey=c1447a53-113b-46d3-976c-bada3638c308&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=032923
With decades of experience supporting payers, Integrity Advantage provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and other organizations fighting healthcare fraud. We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).
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