FWA Briefs

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.

Medicare Reference-based Pricing RAND Study

  • John Danza
  • Jun 11, 2024
  • Comments
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Using the RAND Corporation's newest study to understand payer questions involving Medicare Reference-based Pricing.

Monitor Potential FWA: Overutilization of High-Level Codes

  • Steve Nesnidal, MD, CPC, AHFI
  • Sep 13, 2023
  • Comments
Monitoring Claims for Fraud-canstockphoto25652629

In our latest blog, we discuss a recent OIG report that found Medicare could have saved millions of dollars by monitoring providers who billed the highest reimbursable codes. It shows how certain code descriptions were miscounted by providers, causing higher reimbursements that weren't owed. Click below to learn and read more.

Fraud Spotlight: Why Modifier 25 FWA Continues

  • Steve Nesnidal, MD, CPC, AHFI
  • Jun 07, 2023
  • Comments
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A pain management practice will pay $625k from a False Claims Act violation. Similar cases give an importance to Fraud, Waste, and Abuse (FWA) protection, and the use of E/M codes would have detected an abnormality on similar claims. Read more to find out how.

Medicare and Maine Medicaid Healthcare Fraud Settlement Case

  • Steve Nesnidal, MD, CPC, AHFI
  • May 17, 2023
  • Comments
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A Maine family practitioner used false claims billed to Medicare and Medicaid for services that were either not provided or not medically necessary, which provides reasons for the need of Fraud, Waste, and Abuse (FWA) protection.

Fighting Fraud in Medical Nutrition Therapy

  • Steve Nesnidal, MD, CPC, AHFI
  • Apr 27, 2021
  • Comments
Nutrition

The role of nutrition in chronic disease management is especially crucial, as it is a modifiable risk factor for many conditions such as chronic renal failure (CRF), diabetes mellitus (DM), obesity and coronary artery disease (CAD). Payers who bear significant long-term healthcare utilization burdens due to obesity and cardiovascular risk factors may determine that Medical Nutrition Therapy (MNT) preventive coverage is a cost-effective policy approach for their beneficiaries.

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