Bladder Beware: Flushing out Healthcare Fraud for Urinary Catheters
Urinary catheters and external urinary collection devices are generally covered for patients who have acute (non-routine), permanent urinary incontinence or permanent urinary retention. CMS defines permanent urinary retention as “retention that is not expected to be medically or surgically corrected in that beneficiary within 3 months.” The maximum units allowed per day/month can vary between plans.
Urinary catheters are generally classified into three main categories based on their usage and duration of placement.
- Intermittent Catheters – Inserted into the bladder to drain urine and then removed immediately after the bladder is emptied. They are used periodically, typically several times a day, and are suitable for individuals who can perform self-catheterization.
- Indwelling Catheters (Foley Catheters) – Remain in the bladder for an extended period, providing continuous drainage. They are held in place by an inflatable balloon filled with sterile water. These are commonly used in hospital settings or for patients who require long-term urinary management.
- External Catheters – Primarily used by men, these catheters fit externally and are connected to a drainage bag. They are non-invasive and typically used for patients who experience urinary incontinence.
Vulnerability for Fraud
Claims for urinary catheters are notably vulnerable to fraudulent billing practices, largely due to the relative ease of setting up a medical supply company and the modest expense associated with these products. Consequently, these items often face less rigorous examination compared to more costly medical supplies and/or equipment.
Recent Fraud Schemes with Claims for Intermittent Catheters
In 2023, the Institute for Accountable Care analyzed Medicare claims data for two intermittent urinary catheter codes and discovered CMS payment for these services had escalated from $153 million in 2021, to $3.1 billion in 2023.
The National Association of ACOs (NAACOS) notified the federal government of the review and identified seven durable medical equipment companies that accounted for most payments made by CMS. NAACOS also reported payments for catheters have surged dramatically across almost all 50 U.S. states, with more than half of the states experiencing an increase of 500% or more in Medicare fee-for-service payments from 2022 to 2023.
Billing of Intermittent Catheter Supplies
Intermittent Catheter Billing Codes:
- A4351: Intermittent urinary catheter, straight tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic), each
- A4352: Intermittent urinary catheter; coudé (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic), each
- A4353: Intermittent urinary catheter with insertion supplies
All brands of catheters are billed under the same billing code regardless of the quality of the product.
Detecting Potential Fraud
Fraudulent billing practices related to urinary catheters can include various deceptive tactics. Among these are billing for more catheters than were supplied or ordered, submitting claims for catheters that were not ordered by a physician, billing for catheters when not medically necessary, and billing for catheters along with insertion supplies (A4353) when such kits were not provided.
How to Detect:
- Unusual spike in claims not easily explained by market factors or regulatory changes
- High payments to newly enrolled medical supply companies
- Higher paid per patient values compared to peers
- Claims for supplies reportedly provided 6 or more months prior to claim submission
How Fraud Scope Can Assist in Detection of Fraudulent Billing Practices
Fraud Scope’s pattern-based detection models, such as Suspicious Trends and Outlier Abuse can detect outlier utilization including elevated services for specific codes, elevated services per day, and elevated number of patients. The data collection, analysis by the AI, and charting options of the results will allow the user to identify spikes in a provider’s claims and excessive billing of services.
Fraud Scope’s Query Builder applies healthcare intelligence at the line, claim, or aggregate levels. Users can define criteria specific to their scope of focus.
- Providers with outlier utilization of urinary catheters compared to their peers
- Higher paid per patient values by urinary catheter codes compared to all peers
- Urinary catheters provided to patients without qualifying diagnoses
Fraud Scope’s Association Graph identifies claim relationships between providers using common addresses or common patients. When a user identifies a provider offering excessive services, it might be useful to check if this provider shares a high volume of patients with other providers, as this could suggest patient sharing or kickbacks. Additionally, if the provider shares an address with other providers, it could indicate potential patient sharing or split billing.
Fraud Scope’s Provider Dashboard identifies new providers from your claims traffic, established providers who had discontinued billing and recently submitted claims, and providers submitting a code that did not exist in their history.
References:
Centers for Medicare and Medicaid Services: Local Coverage Determinations/Articles
CMS LCD L33803 – Urological Supplies
CMS ACD A52521 – Urological Supplies Policy Article
Centers for Medicare and Medicaid Services: Spotlight
CMS – Case Study: CMS’ Swift Action on Urinary Catheter Billing Saves Billions
Fierce Healthcare – CMS Officials Say Agency is Monitoring Concerns from ACOs about DME Costs
Fierce Healthcare – ‘A giant unknown’: What the Alleged $2B Medicare catheter fraud scheme means for ACOs
The Washington Post – Medicare Pushes New Payment Rule after Alleged $3 Billion Fraud Scheme
The New York Times – Staggering Rise in Catheter Bills Suggests Medicare Scam
NAACOS – Coalition Letter on DME Spending Impact on ACOs