AMA CPT® Assistant - 2010 Issue 11 (November)
Safeguarding Program Integrity (November 2010)
November 2010 page 7 Safeguarding Program Integrity Audits of health care billing have been used for many years as a method to attempt to ensure accurate payment as well as to detect potential fraud. With more attention in recent years, and even more in recent months, on the high costs of health care and the need to rein in spending, the emphasis on reducing inaccurate payments, as well as wasteful, fraudulent, and abusive practices that impact health care resources, has increased. Iinitiatives to reduce health care costs by identifying potential overpayments or billing abuses include: In November 2009, President...
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Article Overview
This article discusses broad Medicare and federal program integrity initiatives from late 2009 and 2010, including audit-based efforts to identify improper payments and reduce billing abuse. It is aimed at physicians, qualified health care professionals, and practice staff who want to understand the audit environment, the role of CMS and related federal entities, and general compliance considerations. The article also points readers to public resources and appeal-related materials.
Why This Topic Matters
Program integrity initiatives can affect billing workflows, documentation practices, audit exposure, and appeals activity for many types of practices. Understanding the general scope of these efforts helps providers assess compliance readiness and monitor areas that are receiving enforcement attention.
Article Sections
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November 2010 page 7
Introductory publication information for the article.
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Safeguarding Program Integrity
Overview of federal and CMS efforts to reduce improper payments and address billing-related waste, fraud, and abuse.
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Recovery Audit Contractors
Discussion of recovery audit contractor activity, audit focus areas, and the general purpose of the initiative.
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Information for Physicians and Qualified Healthcare Providers
General guidance for practices on audit preparedness, documentation, compliance review, and appeal rights.
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Summary
Closing recap of the article’s main compliance themes and the growing importance of billing oversight.
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Additional Resources
Reference list of public websites and reports related to audits, appeals, and program integrity.
What You Will Learn
- The general purpose of federal program integrity and audit initiatives
- How recovery audit efforts fit into broader payment oversight
- Why documentation and billing compliance matter in audit settings
- What types of provider-facing resources are referenced for further review
- How appeals are discussed in the context of audit activity
Who Should Read This
- Physicians
- Qualified health care professionals
- Practice managers
- Billing and coding staff
- Compliance personnel
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