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,

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

  • Cindy Gallee, JD, RHIA, CHC
  • Jan 25, 2017
  • Comments
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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,

Finding Healthcare Fraud in ICD-10 Using ICD-9 Investigation Schemas

  • John Danza
  • Jul 08, 2016
  • Comments
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An ongoing concern within every payer’s special investigation unit (SIU) has been how to adapt existing investigations and future analytics to ICD-10 codes. The thought of having to recreate years of investigative knowledgeware is daunting enough, but the thought of having to figure out the ICD-10 equivalents of the ICD-9 based knowledgeware make it feel akin to climbing Mount Everest. But those ICD-10 codes are hiding out and getting exploited, so something must be done. Con ...

FWA, Potential Fraud Scenarios,

Combat Hospice Fraud with Careful Review of Claims

  • Cindy Gallee, JD, RHIA, CHC
  • May 19, 2016
  • Comments
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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,

Context to Attend ICAHN 2015 CAH Conference in Springfield, IL

  • Kate Armbruster
  • Nov 06, 2015
  • Comments
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Context4 Healthcare, Inc.is set to attend the 2015 CAH Conference, presented by the Illinois Critical Access Hospital Network (ICAHN), being held November 11-12, 2015 at the Crowne Plaza Hotel in Springfield, IL. According to ICAHN's conference website, this year's "theme, 'Strengthening Our CAHs and Their Communities', centers around the importance of critical access and small and rural hospitals and their vital role in attaining and improving population health."

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

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