If you are seeing claims for the treatment of Kwashiorkor, you may want to conduct a review of each claim containing this diagnosis. In OIG reports filed last month, a review of 305 claims with the diagnosis of Kwashiorkor from three different institutions concluded that 100% of them did not meet billing requirements. This resulted in an overpayment to these institutions of $876,950 in total. Earlier this year, OIG reviewed 891 claims from nine other institutions with this diagnosis, with simi ...

"Unbundling" is a hot topic within the healthcare community and is considered fraudulent if done intentionally to maximize payment. Unbundling occurs when multiple CPT codes are billed for the component parts of a procedure when there is a single code available that includes the complete procedure.The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI or CCI) edits to prevent inappropriate payment of services that should not be reported ...

Context 4 Healthcare will showcase its payer solutions as an exhibitor at the SIIA 34th Annual National Educational Conference & Expo taking place October 5 - 8, 2014 at the JW Marriott Desert Ridge Resort & Spa in Phoenix, AZ. The SIIA National Conference & Expo is the world’s largest event focused exclusively on the self-insurance/alternative risk transfer marketplace, typically attracting more than 1,700 attendees from throughout the United States and from a growing numbe ...

Recently, a fraud scheme was uncovered in Virginia involving a substance abuse clinic and the prescription of Suboxone with accompanying laboratory billing of urine drug screens. The substance abuse clinic prescribed its patients weekly Suboxone, a treatment for opioid addiction, for which a urine drug screen was required at each visit. While the clinic did not accept insurance, the drug screens were provided by a laboratory owned by the same owners as the clinic, which billed insurance up to ...

Outpatient physical therapy claims present an area that has long been fraught with the potential for billing fraud, waste and abuse. The Office of Inspector General (OIG) has issued several reports in past years concerning outpatient physical therapy claims that were not reasonable, not medically necessary and / or not properly documented. Most recently, the OIG has reviewed several high billers of physical therapy according to Medicare and determined one such high biller had a 99% error rate i ...