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Find news and solutions for healthcare payers and providers. Recognize and avoid potential fraud, waste, and abuse scenarios. Real-time clinical claim editing are analyzed to maximize provider reimbursements.

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Keeping a watchful eye on telehealth claims

  • Cindy Gallee, JD, RHIA, CHC
  • Jun 05, 2018
  • Comments
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Telemedicine has grown significantly in recent years due to new technologies and consumer demand. According to an April 2017 study by Grand View Research, the telemedicine market is expected to grow to $113.1 billion by 2025 with an estimated compound annual growth rate (CAGR) of 18.8%. An anticipated 7 million patients in the U.S. will access telemedicine services in 2018, a sharp increase from 350,000 in 2013. Payer reimbursement policies, on the other hand, are slow to adapt to the new services.

FWA, Fraud, Waste and Abuse, Payers, healthcare, payment integrity, SIU, Fraud Prevention, Fraud Schemes,

When fraud causes patient harm, and how to find it before it does

  • Cindy Gallee, JD, RHIA, CHC
  • Apr 17, 2018
  • Comments
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It’s been called the most sinister, the most egregious, the worst kind of health care fraud – providers performing medically unnecessary procedures. When this type of fraud makes the headlines, it is indeed sensational.

FWA, Fraud, Waste and Abuse, Payers, Potential Fraud Scenarios, program integrity, payment integrity, SIU, Fraud Prevention,

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.

FWA, payment integrity, dental fraud, upcoding,

OIG Work Plan FY-2017 - Monitoring Claims for Potential Fraud

  • Cindy Gallee, JD, RHIA, CHC
  • Jan 25, 2017
  • Comments
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The Office of Inspector General (OIG) Work Plan for Fiscal Year 2017 provides useful guidance for healthcare providers and payers to monitor their claims for potential fraud and quality of care concerns. The Work Plan (at https://oig.hhs.gov/reports-and-publications/workplan/) details areas where OIG will focus their review efforts by type of provider.

FWA, Fraud, Waste and Abuse, Potential Fraud Scenarios, Anti-Fraud, OIG,

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 ...

FWA, Fraud, Waste and Abuse, Potential Fraud Scenarios,

Payers Should Be Alert to Fraudulent & Unnecessary Cardiac Procedures

  • Cindy Gallee, JD, RHIA, CHC
  • Oct 26, 2015
  • Comments

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 ...

Fight FWA by Detecting Suspiciously High Claim Volume by Specialty

  • Cindy Gallee, JD, RHIA, CHC
  • Sep 28, 2015
  • Comments

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 ...

Avoid Bad Dreams & Bad Billing - OIG to Audit Sleep Study Services

  • Cindy Gallee, JD, RHIA, CHC
  • Aug 11, 2015
  • Comments

Polysomnography services, or sleep studies, are prone to errors in billing and need to be carefully monitored by payers. Sleep study billing is significantly mentioned as an audit topic in the OIG Work Plan for 2015 and using this plan, a recent OIG report 1 found deficiencies in the payment of sleep study services by a Medicare Administrative Contractor. At issue in this report were duplicate billing of sleep study services and inadequate provider documentation. A sleep study is ...

New Legal Team to Enforce OIG Industry Guidance to Help Stop Fraud

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

Detecting fraud, waste and abuse has become more important than ever with the U.S. Department of Health and Human Services Office of Inspector General (OIG) recently announcing a new legal team dedicated to the enforcement effort. This team will enforce OIG industry guidance by affirmatively litigating against providers who commit fraud through the use of civil monetary penalties and exclusion from federal health care programs. According to Lisa Re, the Chief of the Civil Remedies ...

Facility or Nonfacility? The Wrong POS Can Lead to Costly Overpayments

  • Cindy Gallee, JD, RHIA, CHC
  • May 15, 2015
  • Comments

Payers should have a focus on whether they are receiving the appropriate place of service codes on physician claims. In a recent study of physician claims from 2010 through 2012, the Office of Inspector General (OIG) found that incorrect “nonfacility” place of service appeared on physician claims that should have been coded as “facility” place of service.   These claims were for services that physicians performed in facility settings such as ambulatory surgery ...

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 ...

Avoid Reimbursement Issues Due to Misused E/M Codes & Modifier -25

  • Cindy Gallee, JD, RHIA, CHC
  • Feb 04, 2015
  • Comments

Payers should pay particular attention to physician claims utilizing modifier 25 because this modifier is commonly misused and results in a high claim denial rate. The technical definition for modifier 25 is a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. This modifier is used on the Evaluation and Management (E/M) code when there are other services perfo ...

A Review of Mohs Surgery Claims with Incorrect Coding May Reveal Fraud

  • Cindy Gallee, JD, RHIA, CHC
  • Dec 01, 2014
  • Comments

There are a number of ways a dermatology claim for Mohs surgery can be problematic. But even though there had been a focus on this type of surgery in past years by payers and Recovery Audit Contractors (RACs), legal activity against doctors who allegedly have fraudulently billed Mohs surgery claims has again surfaced, indicating that the issue is not yet resolved. 1 What this means for payers is that since Mohs surgery is a high volume and high expense procedure, it needs to be carefully review ...

Detect Unusual Patterns in Service & Patient Volume in All Specialties

  • Cindy Gallee, JD, RHIA, CHC
  • Nov 14, 2014
  • Comments

Payers should not neglect reviewing dental claims for fraud, waste and abuse. An Office of Inspector General (OIG) report released this month found questionable billing for pediatric dental services, including dentists who provided an aberrant number of services per day and dentists performing an unusual number of services per patient per visit. Also, the OIG found inappropriate billed claims for behavior management services. Though the findings are important for reviewing dental claims, they a ...

Why Quashing Kwashiorkor Overpayments is a Good Lesson for Any Payer

  • Cindy Gallee, JD, RHIA, CHC
  • Oct 31, 2014
  • Comments

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 ...

Tips to Modify Your Modifier Usage: Bundling & Unbundling Compliance

  • Cindy Gallee, JD, RHIA, CHC
  • Oct 14, 2014
  • Comments

"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 ...

Are Your Clinical Lab Drug Screenings Free From Fraud?

  • Cindy Gallee, JD, RHIA, CHC
  • Sep 26, 2014
  • Comments

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 ...

Avoid Overpayment - Review Documentation for Outpatient Therapy Claims

  • Cindy Gallee, JD, RHIA, CHC
  • Sep 11, 2014
  • Comments

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 ...

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