Prevent Catheter Billing Fraud!

Prevent Catheter Billing Fraud!  Health care fraud costs our nation billions of dollars each year. With the Louisiana healthcare budget being drastically cut due to limited funds available, it is imperative that everyone does their part by taking an active role in monitoring claims processed under your plan.

Catheter Billing Fraud Uncovered:

I work for a local, Louisiana based catheter supplier company.  Over the past year, we have on-boarded several new CIC patients that were previously with another catheter supplier.  During our intake processing, we noticed significant billing irregularities while reviewing the EOB statements from their previous catheter supplier.  It is necessary to review the EOB statements to ensure a smooth transition of suppliers and to coordinate bill dates with respect to the patient’s previous billing date.

The insurance fraud that we uncovered included billing for units of catheters that were not delivered to the patients and fraudulent upcoding of the catheter HCPC code.

Explanation of Catheter Billing:

1. All brands of catheters are billed under the same billing code regardless of the quality of the product.
2. Catheter billing codes & allowable amounts for LA Medicaid; private insurance will be slightly higher.

• A4351 (Catheter ONLY); Medicaid allowable is $1.10/catheter
• A4352 (Coudé Catheter); Medicaid allowable is $3.32/catheter
• A4353 (catheter & sterile kit); Medicaid allowable is $4.50/catheter kit

**Exception – There are a few closed system products that have received PDAC approval to be billed under the A4353 code without requiring shipment of the sterile kits

What to look for on your EOB statement: 3 simple steps

1. Quantity/units of catheters billed.  *if quantity not specified then call your insurance to find out.
2. Billing code used in claim (A4351, A4352, or A4353)
3. Claim amount paid: This amount is calculated by: Allowable for the catheter code multiplied by quantity of catheters delivered.  See above allowable amounts for the 3 different catheter codes.  Examples shown below.

Example of Catheter billing: Fraudulent Claim & Same Claim correctly billed
In this example patient* “John Smith” has a doctor’s order for #120 coudé catheters without sterile insertion kits. His insurance is Blue Cross Insurance.  Coudé catheters without kits are billed under the HCPC A4352.

Bottom Line:  Insurance fraud costs everyone and as shown by the example above, the monthly fraudulent over-payments of $598.32 (Incorrect $1,123-Correct $524.88) adds up fast to $7,200 a year!

* Patient “John Smith” case is based on actual example with the patient’s name changed for HIPAA/privacy reasons.