Healthcare Fraud and Abuse Schemes – How to Spot the Patterns

  • Emilia Burlasz
  • Mar 09, 2018
  • Comments
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Before the use of electronic claim submissions and EHRs, the only option payers had to detect fraud, waste and abuse was “foot-on-the-ground” auditing at provider sites. Even today many payers still rely on this manual process. These types of audits are time consuming, expensive and performed after claims have already been paid. Technological advances have radically changed FWA pattern recognition. Today, statistical sampling based physical claim audits aren’t necessary when payers can automate testing 100% of claims.

Payment Integrity,

Dental FWA – Upcoding, Misrepresentation and Diagnosing Unnecessary Treatment

  • Cindy Gallee, JD, RHIA, CHC
  • Jan 16, 2018
  • Comments
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Dental fraud, waste, and abuse (FWA) is often unchecked as most Payer’s dental insurance line represents 10% or less of their total business. The National Health Care Anti-Fraud Association (NHCAA) estimates $68 to $226 billion is lost annually to Fraud, Waste and Abuse (FWA). This means up to $ 22.6 billion in FWA is overlooked annually.

Fraud, Waste and Abuse, Payment Integrity, Dental Fraud, Upcoding,

Virtual Benefits Administrator and Context4 Healthcare, Inc. announce real-time Medicare pricing automation

  • John Danza
  • Oct 04, 2017
  • Comments
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Available to VBA subscribers today, this solution provides real-time Medicare Prospective Payment System (PPS) pricing during claims processing. Direct PPS pricing ensures compliance with the Centers for Medicare and Medicaid Services (CMS). It eliminates complexity and the need to utilize less accurate substitutes like RBRVS.

Pricing, Medicare Pricing, Payment Integrity, UCR, Real-time Solution, Compliance,

EHR systems can’t protect you from the False Claims Act

  • John Danza
  • Aug 11, 2017
  • Comments
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The recent Department of Justice (DOJ) $155 million False Claims Act settlement with eClinicalWorks highlights a problem that has existed in the EHR software industry for a long time.  Any EHR system that attests to do everything for the integrated health system can’t possibly provide the highest possible level of all aspects of functionality.  Some parts of the system will be concentrated upon while others will get just enough attention so the vendor can say they have the ...

Fraud, Waste and Abuse, Program Integrity, EHR Coding, Payment Integrity, Billing Integrity,

Medicare Advantage Plans Under the FWA Microscope

  • Margaret Klasa DC, APN BC
  • Jun 29, 2017
  • Comments

HEALTHCARE  is again the most popular topic for the past few weeks.  Even friends that don’t know much about the industry have asked: what’s going on with Medicare?  Apparently, recent allegations of high dollar medical fraud have raised concerns about Medicare Advantage Plans and Payment Integrity.  One law firm pointed out that this is just the start.  “DOJ’s big settlement — $16.7 million for risk adjustment “upcoding” ...

Fraud, Waste and Abuse, Payment Integrity,

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