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Find news and solutions for healthcare payers and providers. Recognize and avoid potential fraud, waste, and abuse scenarios. Real-time clinical claim editing are analyzed to maximize provider reimbursements.

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OIG Work Plan FY-2017 - Monitoring Claims for Potential Fraud

  • Cindy Gallee, JD, RHIA, CHC
  • Jan 25, 2017
  • Comments
Monitoring Claims for Fraud-canstockphoto25652629

The Office of Inspector General (OIG) Work Plan for Fiscal Year 2017 provides useful guidance for healthcare providers and payers to monitor their claims for potential fraud and quality of care concerns. The Work Plan (at https://oig.hhs.gov/reports-and-publications/workplan/) details areas where OIG will focus their review efforts by type of provider.

FWA, Fraud, Waste and Abuse, Potential Fraud Scenarios, Anti-Fraud, OIG,

Combat Hospice Fraud with Careful Review of Claims

  • Cindy Gallee, JD, RHIA, CHC
  • Dec 05, 2016
  • Comments
Stop Fraud Image - Large

As long as there is profit incentive, fraud by wrongdoers can enter into the healthcare spectrum at any point.  An increasingly common fraud scheme surrounds the care of the end-of-life patient in the hospice setting.  In order for most payers to cover a patient receiving hospice care, a physician’s written certification that the hospice patient is terminally ill with a life expectancy of six months or less is typically required.  Enter the fraud scheme – false certif ...

FWA, Fraud, Waste and Abuse, Potential Fraud Scenarios,

Payers Should Be Alert to Fraudulent & Unnecessary Cardiac Procedures

  • Cindy Gallee, JD, RHIA, CHC
  • Oct 26, 2015
  • Comments

Payers need to be ever vigilant in watching out for evolving fraud schemes. Case in point is a recent healthcare fraud investigation where a cardiologist was convicted of performing unnecessary cardiac procedures and causing unnecessary coronary artery bypass surgeries, which resulted in Medicare and other insurers overpaying $7.2 million over a six-year period. 1 This scheme was particularly dangerous because it not only cost taxpayers a large sum of money, but the health and lives of this doc ...

Fight FWA by Detecting Suspiciously High Claim Volume by Specialty

  • Cindy Gallee, JD, RHIA, CHC
  • Sep 28, 2015
  • Comments

The recent sentencing of a Chicago-area dermatologist for fraudulent medical billing points to the need for detection of suspicious high volume dermatology claims. The dermatologist was sentenced to seven years in federal prison and ordered to pay restitution of $3.7 million, a sentence the judge deemed was warranted due to the seriousness of the offense. 1    At issue was the excessive billing of laser removal procedures for pre-cancerous actinic keratosis when the lesions were in fa ...

Avoid Bad Dreams & Bad Billing - OIG to Audit Sleep Study Services

  • Cindy Gallee, JD, RHIA, CHC
  • Aug 11, 2015
  • Comments

Polysomnography services, or sleep studies, are prone to errors in billing and need to be carefully monitored by payers. Sleep study billing is significantly mentioned as an audit topic in the OIG Work Plan for 2015 and using this plan, a recent OIG report 1 found deficiencies in the payment of sleep study services by a Medicare Administrative Contractor. At issue in this report were duplicate billing of sleep study services and inadequate provider documentation. A sleep study is ...

New Legal Team to Enforce OIG Industry Guidance to Help Stop Fraud

  • Cindy Gallee, JD, RHIA, CHC
  • Jul 08, 2015
  • Comments

Detecting fraud, waste and abuse has become more important than ever with the U.S. Department of Health and Human Services Office of Inspector General (OIG) recently announcing a new legal team dedicated to the enforcement effort. This team will enforce OIG industry guidance by affirmatively litigating against providers who commit fraud through the use of civil monetary penalties and exclusion from federal health care programs. According to Lisa Re, the Chief of the Civil Remedies ...

Facility or Nonfacility? The Wrong POS Can Lead to Costly Overpayments

  • Cindy Gallee, JD, RHIA, CHC
  • May 15, 2015
  • Comments

Payers should have a focus on whether they are receiving the appropriate place of service codes on physician claims. In a recent study of physician claims from 2010 through 2012, the Office of Inspector General (OIG) found that incorrect “nonfacility” place of service appeared on physician claims that should have been coded as “facility” place of service.   These claims were for services that physicians performed in facility settings such as ambulatory surgery ...

Compliance Reports Identify 7 Billing Issues to Monitor for Fraud Risk

  • Cindy Gallee, JD, RHIA, CHC
  • Apr 08, 2015
  • Comments

In a significant compliance report by the Office of Inspector General (OIG), published in March 2015, a large Midwestern academic medical center was found to owe Medicare over $6 million, extrapolated from alleged billing errors in a sample taken for the years 2011 and 2012. OIG identifies seven billing issues as putting hospitals at risk for noncompliance, based on their review at this hospital and other facilities it has reviewed as part of its work plan for this year. It is imperative that p ...

To Avoid Potential Fraud, Payers Should Monitor the LEIE Regularly

  • Cindy Gallee, JD, RHIA, CHC
  • Apr 06, 2015
  • Comments

Payers, especially those with contracts involving federal payments, should be monitoring their providers’ statuses under the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE). The OIG, part of the U.S. Department of Health and Human Services (HHS), is at the forefront of efforts to fight fraud, waste, and abuse in Medicare, Medicaid, and 300 other HHS services. 1 The OIG maintains the LEIE, which is a list of all individuals and entities excluded from rece ...

Avoid Reimbursement Issues Due to Misused E/M Codes & Modifier -25

  • Cindy Gallee, JD, RHIA, CHC
  • Feb 04, 2015
  • Comments

Payers should pay particular attention to physician claims utilizing modifier 25 because this modifier is commonly misused and results in a high claim denial rate. The technical definition for modifier 25 is a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. This modifier is used on the Evaluation and Management (E/M) code when there are other services perfo ...

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