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 ...

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 ...

MACs Revise LCDs Due to ICD-10 Errors Reported After Transition Date

  • Margaret Klasa DC, APN BC
  • Nov 19, 2015
  • Comments

The October 1, 2015, ICD-10 mandated code change caused some issues for 8 of the 12 Medicare Jurisdictions that impact at least 32 states. Some of the Medicare Administrative Contractors (MACs) relied on the General Equivalence Mappings (GEMs) to map ICD-9 to ICD-10 codes, which was insufficient for the Local Coverage Determinations (LCDs). Most of the GEM mappings provide unspecified codes and where ICD-9 LCDs relied on exact codes the GEM mappings are unspecified. The announcement by the Cent ...

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."

Outsourced Coding Vendors Face ICD-10 Challenges Related to Transition

  • Margaret Klasa DC, APN BC
  • Oct 29, 2015
  • Comments

The October 1, 2015 implementation date for ICD-10 has finally come and gone. While many industry experts had predicted complete chaos, shut-downs and major loss of productivity, as we enter the last week of October, only some of those predictions have come to fruition. It has been extremely quiet on both the provider and payer ends in the month of October. Some have even suggested that all these predictions of doom have come to resemble the Y2K nightmare that never materialized. Or it could be ...


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