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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.

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.

FWA, Fraud, Waste and Abuse, Payers, healthcare, payment integrity, SIU, Fraud Prevention, Fraud Schemes,

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.

FWA, Fraud, Waste and Abuse, Payers, Potential Fraud Scenarios, program integrity, payment integrity, SIU, Fraud Prevention,

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, provider pattern recognition,

Dental FWA – Upcoding, Misrepresentation and Diagnosing Unnecessary Treatment

  • Cindy Gallee, JD, RHIA, CHC
  • Jan 16, 2018
  • Comments
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Dental fraud, waste, and abuse (FWA) is often unchecked as most Payer’s dental insurance line represents 10% or less of their total business. The National Health Care Anti-Fraud Association (NHCAA) estimates $68 to $226 billion is lost annually to Fraud, Waste and Abuse (FWA). This means up to $ 22.6 billion in FWA is overlooked annually.

FWA, payment integrity, dental fraud, upcoding,

Virtual Benefits Administrator and Context4 Healthcare, Inc. announce real-time Medicare pricing automation

  • John Danza
  • Oct 04, 2017
  • Comments
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Available to VBA subscribers today, this solution provides real-time Medicare Prospective Payment System (PPS) pricing during claims processing. Direct PPS pricing ensures compliance with the Centers for Medicare and Medicaid Services (CMS). It eliminates complexity and the need to utilize less accurate substitutes like RBRVS.

medicare, payment integrity, decisionpoint, UCR, Real-time solution, compliance,

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