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FRAUD, WASTE, AND ABUSE PREVENTION
COVID-19

Q&A: Highmark's payment integrity director on new COVID-19 claim trends

Cotiviti's Signature Series features interviews with senior health plan leaders on how to improve clinical and financial outcomes in healthcare.

During the COVID-19 pandemic, health plans have seen claim volume drop markedly, coding guidelines change regularly, and new care models such as telehealth burgeon. All this change occurring in fewer than six months has forced health plans to rapidly adapt while ensuring members and provider relationships remain well cared for.

In a recent webinar, Highmark BlueCross BlueShield (Highmark) director of payment integrity Drew Satriano explained the steps his organization has taken to mitigate the impact of COVID-19, including using Cotiviti’s Coding Validation solution to monitor a troubling increase in telehealth claims with high-level Evaluation and Management (E&M) codes.

What approach has Highmark taken during the current COVID-19 environment?

Highmark is generally aggressive when it comes to payment integrity. We work with all the major vendors, including Cotiviti, and focus a lot of our efforts on pre-payment. But during COVID-19, we made changes to our pre-payment processes, such as removing certain logic around denials and ambulance modifiers. We tried to do what was in favor of the providers and communicated with them frequently.

Normally, we issue technical denials when requested medical records are not received within 30 days. However, many providers sent non-essential office staff home, including those responsible for sending us medical records, so we tried to be understanding. We also paid out incentive bonuses to our providers ahead of schedule because we wanted to ensure physicians treating COVID-19 patients were paid. Overall, we relaxed certain standards upfront and then addressed any issues that came to our attention on the back end.

How has COVID-19 impacted Highmark’s claim volume?

At one point, our claims were down 50 percent from where they traditionally were. As of June, they're still down about 25 percent. Luckily, we didn’t see as big of a decline as we expected in submission of medical records or itemized bills, but anytime you have a decline in claim submissions you're also going to have a decline in savings.

How did Highmark respond to code set changes related to COVID-19?

We made changes in a timely manner and were conservative in a way that favored providers. We added more codes to the list of COVID-19 exceptions beyond what the Centers for Medicare & Medicaid Services (CMS) required to improve provider billing and get providers paid as quickly as possible.

What fraud, waste, and abuse (FWA) trends is Highmark seeing?

The pandemic has opened the door for incorrect coding and possible fraud. The CARES Act called for a 20 percent increase in reimbursement for COVID-19-related diagnoses. While this provision was meant to increase reimbursement for Medicare and the uninsured population, the use of COVID-19 as the primary or secondary diagnosis on a claim has impacts to commercial insurers as well. Providers that indicate COVID-19 on their claim will ultimately have their claim treated differently than a normal claim submission. Because Highmark relaxed many rules on the front end, we had to catch fraudulent activity on the back end.

What is Highmark seeing regarding telehealth usage?

The FAIR Health organization is showing a 4,000 percent increase in telehealth visits and a 30 to 40 percent increase in telehealth usage for infectious disease, hypertension, and routine office visits. Highmark's data correlates closely with this trend. To put this in perspective: in 2019 Highmark had 15,000 telehealth visits; in Q1 of 2020 alone, we saw over 400,000 telehealth visits.

What conversations and questions are happening in the market?

Telehealth

We’re having conversations about the appropriateness of telehealth visits when we return to the “new normal.” For example, should a new member seeking a first-time wellness visit utilize telehealth, or would that be more appropriate for a traditional office setting? We recently had a doctor tell us that he doesn't want to go back to brick-and-mortar—he wants to conduct all his visits via telehealth because he can see more patients more efficiently. So, we’re having conversations about what, if any, differences in reimbursement should be made for a telehealth visit versus an in-person visit.

Rebates

Similar to the auto insurance industry, we’re getting questions about premium refunds or rebates. Some auto insurers gave back premium dollars to their enrollees due to a decrease in automobile usage during quarantine. Likewise, there was a significant decrease in medical utilization, with elective procedures essentially cancelled, so now we’re seeing requests for unutilized healthcare premiums to be refunded.

Enrollment

There are many questions about how unemployment will impact enrollment, especially as employer groups permanently close their doors. According to May reports, more than 100,000 small businesses had closed permanently since the pandemic escalated in March. Approximately 47 percent of private-sector employees work at small businesses so it's a matter of how long they can hold on.

Fortunately, we haven't seen a huge decrease in enrollment at Highmark, but I’ve talked to a lot of other Blue Plans and they're projecting up to 20 percent enrollment loss. We anticipate a lot of people will move to Medicaid and Affordable Care Act (ACA) plans.

What other actions is Highmark considering?

It’s concerning that telehealth claims are being coded at E&M level four and five. We need to determine if telehealth is the appropriate setting for this. Highmark recently implemented Cotiviti's Coding Validation solution, which focuses on E&M over-coding and incorrect modifier usage. This area is generally high-volume, low dollar, so most payers don't put a lot of emphasis on it. But now, payers may want to start exploring new technical solutions and focus more on E&M over-coding.

Highmark continues to evaluate the decisions we made to determine if we were too broad in what we defined as COVID-19-related. We're also focusing our efforts on areas that could be COVID-19-related but are not coded that way, such as short-term ventilator usage and respiratory-related DRGs. We're seeing an increase in complications and co-morbidities related to COVID-19, which increase DRGs and payment.

Has Highmark thought about covering broader use of telemedicine, such as remote blood pressure cuffs and other similar type items?

Highmark is in a unique situation because we are both an insurer and a major provider of healthcare in our region. So yes, we're working with technology companies and evaluating all uses of telehealth. I think in a year from now, we won't even mention the word “telehealth,” because it will just be the new norm. We’re working with technology vendors and medical device vendors to help educate our members and ensure they can manage their health virtually.

Drew Satriano, director of payment integrity for Highmark BlueCross BlueShield, has been with the organization for more than 24 years and is responsible for building its payment integrity program.


For more insights from Highmark and Cotiviti, watch our on-demand webinar “Finding payment integrity success in an evolving COVID-19 environment.”

Watch the webinar

WRITTEN BY

Michael Jablon
As vice president of product for Cotiviti, Michael leads product development and management for prospective payment accuracy solutions.

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FRAUD, WASTE, AND ABUSE PREVENTION

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Q&A: Highmark's payment integrity director on new COVID-19 claim trends

Michael Jablon

Aug 17, 2020

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