COVID-19 billing observations and information

We released an Audit Spotlight in our last newsletter related to a COVID-19 claim. The claim example generated many questions from the brokers and clients we work with. As such, we have summarized additional ClaimDOC observations and insights regarding COVID-19 and health insurance claims.

As COVID-19 emerged, ClaimDOC observed a decrease in claims for nonemergency surgeries and office visit services. While only temporary, these services are essential contributions to patient health. 

ClaimDOC has recently seen an acceleration of claims being submitted for patients either being screened for COVID-19 or patients having a definitive diagnosis of COVID-19, either with no symptoms, mild symptoms, or extremely severe symptoms. Claims reported/billed with only a single diagnosis of COVID-19 appear rare. Most claims contain additional signs, symptoms, or other diagnostic codes. It is anticipated that any related long-term patient effects may not be known for some time. 

According to the Centers for Disease Control and Prevention (CDC) website, three levels of evidence are outlined with corresponding medical conditions that put adults, of any age, at increased risk for severe illness for the virus causing COVID-19. Conditions such as type 2 diabetes mellitus, obesity, coronary artery disease, smoking, and several others fall in the strongest and most consistent evidence risk level. The CDC list is a “living document,” which is periodically updated as science evolves. 

While congress requires insurers to cover COVID-19 collection and testing, we also see egregious prices for collection and testing among states, laboratories, and providers. From our claim analyses perspective, there does not appear to be any special or differences in technology from one provider laboratory to another when the same CPT/HCPCS code (test) is furnished to the patient. Are providers “taking advantage” of federal requirements knowing insurers pay for the costs of tests and, therefore, inflate their charges because they understand they will be reimbursed for their costs? 

Examples of Charge Variations

  • CPT code 87635 $55.00 – $10,400 (no, not a typo)
  • HCPCS code U0001 $0.10 – $350.00
  • HCPCS code U0002 $27.28 -$300.00
  • HCPCS code U0003 $100.00 – $368.00
  • HCPCS code U0004 $44.00 – $368.00
  • HCPCS code C9803 $18.20 – $99.00

In some cases, hospital websites post their charge for COVID-19 tests as being “free” to uninsured and insured patients. Another question arises when claims are subsequently billed to insurance with costs of $75.00, $100, or $150.00 for the reportedly “free” COVID-19 test. Some insurers have announced they will not pass costs for COVID-19 tests and care along to their members, at least for now. 

As an important side note, the Office of Inspector General (OIG) has alerted the public about fraud schemes related to COVID-19. Scammers offer tests in exchange for personal details, including Medicare/Medicaid information, or offering gift cards, when no such cards exist. In October 2020, the OIG announced five new audits added to the OIG Work Plan specific to COVID-19 issues. Additionally, as part of the mission to improve and protect the healthcare system, many commercial health plans have partnered with state and federal agencies, as well as advocacy organizations, to report, investigate and reduce the incidence of healthcare fraud.

There is a consensus that we will be dealing with the effects of COVID-19 for the foreseeable future, and recoveries back to economic health will take time. While the COVID-19 has presented drastic changes and challenges, we will continue to learn from this pandemic.