"Fraud" Articles

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April 20th, 2020

Now That is Fraud! Genetic Testing "Public alert"

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020

Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...

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May 17th, 2019

An Update on the DHS OIG's Effort to Combat Fraud & Abuse

By Namas | Published May 17th, 2019 - Last Review/Update May 21st, 2019

An Update on the DHS OIG's Effort to Combat Fraud & Abuse Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...

April 23rd, 2019

What is Medical Necessity and How Does Documentation Support It?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019

We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

March 21st, 2019

The Impact of Medical Necessity on High Level E/M Services

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019

I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?" The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

March 1st, 2019

Understanding NCCI Edits

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

January 10th, 2019

Are You Protecting Your Dental Practice From Fraud?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019

With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...

November 28th, 2018

No Good Deed Goes Unpunished

By Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA | Published November 28th, 2018 - Last Review/Update January 21st, 2019

You simply need to read the headlines, posts, and tweets, about providers across the healthcare profession being audited, fined, and some even convicted, to see that the costs of non-compliance are real. We tell ourselves, “It won’t happen to me.” The reality is that it easily could. Your license is your livelihood.

May 30th, 2018

Creating a Culture of Compliance in 2018

By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018

This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...

April 20th, 2018

The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?

By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018

As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....

January 29th, 2018

Dental and Medical- Controlled Substance Awareness

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2018

As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...

September 14th, 2017

Double Dipping in the History of the Evaluation and Management Note

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history. The subcomponents of history include: Chief Complaint ...

July 31st, 2017

Health Care Fraud - Don’t Do It!

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 31st, 2017

If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don't need to tell you this. I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate ...

June 23rd, 2016

Hundreds arrested for $900 million worth of health care fraud

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 23rd, 2016

CNN reported an astounding number of individuals charged with false billing. There was about $900 million in false billing that involved Medicare and Medicaid fraud. Along with the $900 in false billing, $36 million in Detroit involved a front for a narcotics diversion scheme. There were 301 defendants charged in ...

April 5th, 2016

Voluntary Disclosure - Look Before You Leap

By ChiroCode | Published April 5th, 2016

Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.

February 15th, 2016

Unified Program Integrity Contractors (UPIC)

By InstaCode Institute | Published February 15th, 2016

CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.

February 1st, 2016

Will Incident-To in Your Organization Pass a Compliance Audit?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016

Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.

August 19th, 2015

Chiropractic Listed as Focal Point in 2015 OIG Work Plan

By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017

With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...

August 10th, 2015

Alphabet Soup for Waste and Fraud Inspectors

By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017

The following are some of the acronyms you would need to know when communicating with auditors: National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice. Medically Unlikely Edits (MUE): Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code. Office of the ...

February 26th, 2015

Avoiding Medicare and Medicaid Fraud and Abuse

By | Published February 26th, 2015 - Last Review/Update January 27th, 2017

Recently, the U.S. Department of Health and Human Services Office of Inspector General updated their booklet, “Avoiding Medicare and Medicaid Fraud and Abuse.” In this publication, the Government agencies, including the Department of Justice, the Department of Health and Human Services office of Inspector General, and the Centers for Medicare and ...

December 4th, 2014

CMS - Final Rule to Deny or Revoke the Enrollment of Entities that Pose an Integrity Risk to Medicare

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016

On December 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare. This fact sheet summarizes CMS’ regulatory additions and changes. SUMMARY OF THE PROVIDER ...

November 19th, 2014

Understanding ZPIC

By | Published November 19th, 2014 - Last Review/Update January 30th, 2017

The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.

November 19th, 2014

Understanding RAC

By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017

Recovery Audit Contractors, also known as RAC,Â is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries.Â This includes both recoupment of overpaymentsÂ and corrected distribution of underpayments made by CMS. Â RAC began in 2005 as a three-year demonstration project consisting ...

November 7th, 2014

Q & A: 97022 and Dry Hydromassage

By | Published November 7th, 2014 - Last Review/Update January 30th, 2017

Is it appropriate to use 97022, whirlpool, to report dry hydromassage? The CPT code 97022 is defined simply as “Application of a modality to 1 or more areas; whirlpool”. The CPT book does not expand on the code. However, in 2002, the CPT manual added this phrase to the general guidelines: Do not select a ...

October 16th, 2014

The Role of Statistical Analysis in Fighting Fraud

By Jared Staheli | Published October 16th, 2014 - Last Review/Update January 30th, 2017

It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. New developments in statistical analysis helps to combat this.

September 25th, 2014

Healthcare Fraud Investigations in FY 2013

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017

Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 ...

September 9th, 2014

Cyber Insurance? What kind of Insurance Policy it that?

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2014 - Last Review/Update January 30th, 2017

Due to the increase of medical transactions stored online and in the cloud, cyber intrusions will only increase. Cyber insurance also known as privacy and network security insurance can help cover the costs incurred if your computer system is compromised, or after a data breach which can include a HIPAA ...

September 9th, 2014

Compliance Specialists

By | Published September 9th, 2014

Compliance specialists are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, ...

September 24th, 2013

Federal Health Care Fraud Summary 2012

By | Published September 24th, 2013 - Last Review/Update January 27th, 2017

Be aware of the possible monetary results and enforcement actions imposed for fraud. This is the annual report of the Department of Justice Health Care Fraud and Abuse Control Program for FY 2012

July 15th, 2013

Medicare Recruits Seniors to Fight Against Fraud

By | Published July 15th, 2013 - Last Review/Update January 27th, 2017

Recently Medicare issued a press release about their updated Medicare Summary Notice. The Obama Administration has made the elimination of fraud, waste, and abuse a top priority and the number of providers thrown out of Medicare programs has more than doubled in the last few years. The newly designed Medicare ...

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