Payers need to be ever vigilant in watching out for evolving fraud schemes. Case in point is a recent healthcare fraud investigation where a cardiologist was convicted of performing unnecessary cardiac procedures and causing unnecessary coronary artery bypass surgeries, which resulted in Medicare and other insurers overpaying $7.2 million over a six-year period. 1 This scheme was particularly dangerous because it not only cost taxpayers a large sum of money, but the health and lives of this doc ...

Conference attendees will have the chance to learn about a new product this year - just recently, Context introduced a new Inpatient UCR module as part of its DecisionPoint™ Health Payment System. With the increasingly high cost of inpatient services, many valued UCR customers have been looking for a way to benchmark inpatient facility claims. As the trusted source for UCR fee data (including Medical, HCPCS, Anesthesia, Dental and Outpatient), Context has developed an independent source for inpatient charges for more than 740 Diagnosis-Related Groups (DRGs).

The recent sentencing of a Chicago-area dermatologist for fraudulent medical billing points to the need for detection of suspicious high volume dermatology claims. The dermatologist was sentenced to seven years in federal prison and ordered to pay restitution of $3.7 million, a sentence the judge deemed was warranted due to the seriousness of the offense. 1    At issue was the excessive billing of laser removal procedures for pre-cancerous actinic keratosis when the lesions were in fa ...

October 1, 2015, and beyond will certainly bring on the challenges for both providers and payers – from revenue cycle complications to compliance and technical issues that will be a hurdle to overcome on both ends of the payer and provider sides. Some segments of the insurance industry are not required to follow suit and transition to the new ICD-10 coding set, however that does not mean they will be untouched by this transition and will spend an increased amount of time sorting and ident ...

Context4 Healthcare, Inc. will showcase its FirstPass™ claim editing solution as an exhibitor at the 2015 PLEXIS CONNECT Users Conference taking place September 20 - 23 in Ashland, OR. Context’s FirstPass™ claim editing solution is pre-integrated with the PLEXIS QC™ Quantum Choice system within the adjudication process. Using the FirstPass™ real-time web services capability, FirstPass™ edits each claim almost instantly and returns the results to Quantum Choic ...