"OIG" & "Fraud" Articles


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OIG – Fraud and Abuse Study with COVID-19 Testing

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According to the Office of Inspector General (OIG), “The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example, to confirm or rule out diagnoses ...

OIG Report Highlights Need to Understand Guidelines

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A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

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We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...

Now That is Fraud! Genetic Testing "Public alert"

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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 ...

The OIG Work Plan: What Is It and Why Should I Care?

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The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...

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

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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 ...

OIG Announces New Review For Medicare Part B Payments for Podiatry and Ancillary Services

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Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020.  The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.   Part of the ...

What is Medical Necessity and How Does Documentation Support It?

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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 ...

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

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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. ...

Understanding NCCI Edits

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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 ...

Are You Protecting Your Dental Practice From Fraud?

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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 ...


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