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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.

Detecting Healthcare Fraud, Waste, and Abuse

  • Steve Nesnidal
  • Jul 30, 2019
  • Comments
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A key step in the fight against Fraud Waste and Abuse (FWA) in healthcare is the detection of an aberrancy of significance--some atypical pattern that you would not normally expect to see within a batch of legitimate claims. Although isolated errors are consistently made in claims submission, tools which can help see beyond them and isolate patterns that are suspicious for fraud on a grand scale, or at least waste or abuse of a significant scope, can prove valuable.

Fraud, Waste and Abuse,

Combating Overutilization of Healthcare Resources

  • Steve Nesnidal
  • Feb 04, 2019
  • Comments
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Overutilization in Healthcare is a problem which has been estimated to cost in the range of hundreds of billions of US dollars every year. Despite historically spending more than double per person on healthcare than the average developed country, our outcomes have not been significantly better. To improve, specialty organizations publish clinical quality initiatives and practice guidelines that support consistent, focused, evidence-based care.

Fraud, Waste and Abuse, ICD-10, Payment Integrity, Overutilization,

Keeping a watchful eye on telehealth claims

  • Cindy Gallee, JD, RHIA, CHC
  • Jun 05, 2018
  • Comments
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Telemedicine has grown significantly in recent years due to new technologies and consumer demand. According to an April 2017 study by Grand View Research, the telemedicine market is expected to grow to $113.1 billion by 2025 with an estimated compound annual growth rate (CAGR) of 18.8%. An anticipated 7 million patients in the U.S. will access telemedicine services in 2018, a sharp increase from 350,000 in 2013. Payer reimbursement policies, on the other hand, are slow to adapt to the new services.

Fraud, Waste and Abuse, Payers, Payment Integrity, SIU,

When fraud causes patient harm, and how to find it before it does

  • Cindy Gallee, JD, RHIA, CHC
  • Apr 17, 2018
  • Comments
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It’s been called the most sinister, the most egregious, the worst kind of health care fraud – providers performing medically unnecessary procedures. When this type of fraud makes the headlines, it is indeed sensational.

Fraud, Waste and Abuse, Payers, Program Integrity, Payment Integrity, SIU,

Healthcare Fraud and Abuse Schemes – How to Spot the Patterns

  • Emilia Burlasz
  • Mar 09, 2018
  • Comments
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Before the use of electronic claim submissions and EHRs, the only option payers had to detect fraud, waste and abuse was “foot-on-the-ground” auditing at provider sites. Even today many payers still rely on this manual process. These types of audits are time consuming, expensive and performed after claims have already been paid. Technological advances have radically changed FWA pattern recognition. Today, statistical sampling based physical claim audits aren’t necessary when payers can automate testing 100% of claims.

Payment Integrity,

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