When providers bill for services outside of their area of expertise, there’s a risk that patients may not receive the most appropriate or effective care. Many payers and regulatory agencies require providers to bill only for services within their approved specialty, while licensing ensures that providers have met the necessary education, training, and competency standards. Billing outside of one’s specialty can violate these policies, leading to penalties, audits, or even exclusion from government programs.
In this edition of FWA Insights, we break down the steps special investigative units (SIUs) can take to determine if a provider has billed for illegitimate services outside of their specialty to help ensure regulatory compliance and reduce fraud, waste, and abuse (FWA).
Investigative steps
While there may be legitimate reasons for billing outside of one’s specialty, it can also be a sign of intentional fraud, like billing for unrendered services or circumventing prior authorization requirements. Billing for higher-cost or unnecessary services—also known as upcoding—drives up healthcare spending and can affect insurance premiums, leading to increased costs for payers and patients.
For example, if a cardiologist bills for procedures codes 51702 (insertion of a temporary bladder catheter), or 99395-99397 (preventative medicine visits), these codes may be flagged as atypical for this healthcare specialty. Other common examples Cotiviti’s SIU has observed include:
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Anesthesia services: Administering general anesthesia typically requires an MD or DO anesthesiologist, or a Certified Registered Nurse Anesthetist (CRNA) or anesthesiologist assistants (AA) with appropriate state licensure and certification. Individuals without this credential are not expected to be administering anesthesia.
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Cardiac catheterization: Per CMS LCD L30719, “Cardiac catheterizations will be payable when performed by the following specialties: 06-Cardiology, 78-Cardiac Surgery.” Providers billing for these services without one of the aforementioned specialties should be reviewed further to ensure subspecialties are accounted for and that all billing policies are being met.
Health plan SIUs can follow these four steps to help determine if claims are valid.
Documentation review
Thoroughly examine claim documentation, including medical records, billing notes, provider credentials, and any supporting paperwork. Confirm the relationship between the billing and rendering provider by validating that the individual who performed the service is appropriately credentialed and that the billing structure accurately reflects how services were delivered.
This helps ensure that services are not being misattributed to a provider whose specialty or credentials would otherwise make the billing appear compliant, and includes verifying:
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The rendering provider is identified on the claim when required and is licensed and credentialed to perform the service
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The billing provider (individual or group) has a legitimate relationship to the rendering provider (e.g., employment, contracted group, or supervising physician)
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Services billed under group or facility NPIs align with the specialties and qualifications of the actual rendering providers
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Any use of supervisory, incident-to, or shared billing arrangements complies with payer policies and regulatory requirements
Provider credential verification
Check provider certifications, licenses, and specialty designations. Confirm whether the provider is authorized to perform the billed procedures and if any additional training or cross-specialty permissions exist.
Data analysis
Data analysis allows organizations to spot billing behaviors that don’t align with a provider’s specialty, such as outlier procedures or high volumes of aberrant claims. Investigators analyze patterns over time, looking at the frequency and context of out of specialty billing. They compare the provider’s billing practices with peers in the same specialty and assess if the behavior is consistent with legitimate exceptions or is anomalous.
Investigators should also validate the underlying data, including confirming that provider specialty designations are accurate and accounting for sub-specialties, dual specialties, or group billing structures. This helps ensure comparisons are appropriate and reduces the risk of misidentifying legitimate behavior as suspicious.
Regulatory and policy review
Review relevant payer policies, CMS guidelines, and state regulations to assess compliance. Research to understand procedure requirements and provider qualification requirements. Validate the provider’s credentials outside of claims data and ensure all pieces of the puzzle have been gathered when completing compliance review, as this helps determine whether the provider’s actions violate any rules, laws, or is explainable.
Key takeaways
Billing outside of a provider’s specialty can be a red flag for FWA. Health plan SIUs should apply thorough documentation reviews and data analysis to their own operations to help reduce improper billing outside of provider specialties. Accurate credentialing and specialty-based billing are essential for regulatory compliance and for maintaining the integrity of the health care system. Continuous monitoring for suspicious claims by using data analytics, provider education, and comprehensive record reviews is crucial for effective detection and prevention.
Webinar: Waste and abuse in behavioral health
As treatment models expand and coding and documentation requirements continue to change, bad actors behavioral health services are vulnerable to exploitation. Watch our recent on-demand webinar as Cotiviti’s behavioral health and FWA experts discuss:
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The latest guidance designed to stop Medicaid fraud and abuse
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How emerging behavioral health trends are being exploited by bad actors
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Key takeaways from the recent federal release of behavioral health provider data
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Tools and approaches to identify and stop FWA without creating provider abrasion
