Compliance Reports Identify 7 Billing Issues to Monitor for Fraud Risk

  • Cindy Gallee, JD, RHIA, CHC
  • Apr 08, 2015
  • Comments

In a significant compliance report by the Office of Inspector General (OIG), published in March 2015, a large Midwestern academic medical center was found to owe Medicare over $6 million, extrapolated from alleged billing errors in a sample taken for the years 2011 and 2012. OIG identifies seven billing issues as putting hospitals at risk for noncompliance, based on their review at this hospital and other facilities it has reviewed as part of its work plan for this year. It is imperative that p ...

To Avoid Potential Fraud, Payers Should Monitor the LEIE Regularly

  • Cindy Gallee, JD, RHIA, CHC
  • Apr 06, 2015
  • Comments

Payers, especially those with contracts involving federal payments, should be monitoring their providers’ statuses under the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE). The OIG, part of the U.S. Department of Health and Human Services (HHS), is at the forefront of efforts to fight fraud, waste, and abuse in Medicare, Medicaid, and 300 other HHS services. 1 The OIG maintains the LEIE, which is a list of all individuals and entities excluded from rece ...

Identify Potential Fraud for Home Health Trends in E/M, Outliers & POS

  • Cindy Gallee, JD, RHIA, CHC
  • Feb 27, 2015
  • Comments
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Investigators have long considered Home Health claims to be rife with the potential for fraud. The daily news illustrates this point as fraud convictions of Home Health operators appear regularly. Last week, an owner of a Miami Home Health company pleaded guilty to a $13 million fraud, perpetuated by kickbacks and bribes to patients and medical providers for referrals and prescriptions that were used to fraudulently bill Medicare . 1 Data indicating fraud in home health claims has important imp ...

Context 4 Healthcare, Inc. Can Solve Your GEM of an ICD-10 Problem

  • Margaret Klasa DC, APN BC
  • Feb 20, 2015
  • Comments

Most healthcare professionals - from vendors to coders to physicians - are concerned about one aspect of the upcoming, mandated transition to the ICD-10 code set slated for October 1, 2015. A growing consensus across the healthcare industry is that the commonly used General Equivalence Mappings (GEMs ) files, published by the Centers for Medicare & Medicaid Services (CMS), are not enough to ensure accurate and appropriate results between ICD-9 and ICD-10 codes. Both in forward and reverse m ...

U.S. House Committee to Hold ICD-10 Implementation Hearing Today

  • Margaret Klasa DC, APN BC
  • Feb 11, 2015
  • Comments

The U.S. House Energy and Commerce Committee ’s subcommittee on healthcare is holding a hearing on ICD-10 implementations today, Wednesday, February 11, 2015. The Subcommittee on Health, chaired by Rep. Joe Pitts (R-PA), titled this meeting, “Examining ICD-10 Implementation” and subcommittee members will hear from a number of ICD-10 stakeholders. This subcommittee has been working with the Centers for Medicare and Medicaid Services ( CMS ) for several months to ensure this de ...


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