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.

FWA, 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.

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,

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,

EHR systems can’t protect you from the False Claims Act

  • John Danza
  • Aug 11, 2017
  • Comments
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The recent Department of Justice (DOJ) $155 million False Claims Act settlement with eClinicalWorks highlights a problem that has existed in the EHR software industry for a long time.  Any EHR system that attests to do everything for the integrated health system can’t possibly provide the highest possible level of all aspects of functionality.  Some parts of the system will be concentrated upon while others will get just enough attention so the vendor can say they have the ...

FWA, program integrity, EHR coding, payment integrity, Billing Integrity,

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