In October, the National Health Care Anti-Fraud Association (NHCAA) held its annual training conference that spotlighted emerging fraud schemes. In addition to updates on the brace, genetic testing, and foot bath schemes, some newer schemes, trends, and risk areas were discussed. BluePeak also highlighted the bath schemes, that have been ongoing for many months, after the MEDIC conference this past summer.
Medical Scheme
Improper billing of “P-Stim” devices. In this scheme, providers are billing thousands of dollars for the implantation of neurostimulator electrodes, a surgical procedure typically performed in an operating room. However, these providers are not actually performing surgery, but rather applying a “P-Stim” device in an office setting without surgery or anesthesia. A P-Stim device is a single-use, battery-powered, acupuncture device that is affixed behind a patient’s ear using an adhesive. Once activated, the device provides intermittent stimulation by electrical pulses. It is designed to be worn for approximately four days until its battery runs out and then thrown away. Beyond P-Stim, other brand names for this type of device include Stivax, NeuroStim, ANSiStim, E-Pulse, and NSS-2 Bridge. Especially if, like Medicare, your plan does not reimburse for acupuncture or neurostimulator/acupuncture devices such as P-Stim, you should be aware of this scheme.
Pharmaceutical Schemes
Be conscious of the following emerging threats, as related to drugs being frequently abused. When these medications are prescribed, plans should confirm the enrollee has been diagnosed with a condition the drug is approved to treat:
- Certain type 2 diabetes treatments can result in weight loss (SGLT2, incretin mimetics, Farziga), and are being diverted for that reason.
- Buprenorphine, stimulants (Ritalin, Concerta, Adderall, Dexedrine, Evekeo, Strattera, Vyvanse, Focalin, Quillivant), and certain HIV prophylaxis drugs (PrEP Therapy Truvada, Descovy) are showing a pattern of diversion to be used as potentiators with other drugs.
- Spravato, a nasal spray to treat major depression, is being diverted for use as a date rape drug.
- Expensive, new, non-controlled medications to watch for possible waste:
- Diabetes medications: Rybelsus, Nesina, Kazano
- Insulin: Myxredlin
- Glucagon: Gvoke, Baqsimi
- Vaccine for monkeypox
- Immune system: Rinvoq, Inrebic, Ruxience
Billing Scheme
To help reduce the opportunity for fraudulent claims before they even have the opportunity to enter into your system, consider putting in place a system to authenticate non-participating providers before setting them up in your plan’s claims payment system. Require each non-participating provider provide a W-9 and license verification to authenticate the provider and stop fraudsters before you pay a single claim.
Update on Foot Bath Scheme
On November 20, CMS released a memo highlighting the foot bath scheme. CMS stated beneficiaries are provided a foot spa free of charge, with instructions from the pharmacy to mix the medications with water to soak their feet. These medications are often dispensed without medical necessity or pursuant to true medical relationships. In addition, they may be of limited clinical value and may be harmful to patients, if used as dispensed.
BluePeak is recommending that clients pull dispensing reports for antibiotic and anti-fungal medications (both in and out of compounds) to see if there were high volumes for either a particular pharmacy or prescriber NPI for targeted review.
