decisionhealth Newsletters, Answer Books - 2009 Issue 1 (January)
Answer_Book / Fraud_and_Abuse / PROs_brought_in_for_abuse_cases
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Article Overview
This premium article covers the role of peer review organizations in abuse-related reviews, including how a case may be referred, how the review process may involve medical personnel and the physician, and what can happen when a decision is issued or appealed. It is relevant to coding and compliance professionals, auditors, physicians, and other readers working with fraud-and-abuse procedures and administrative review processes.
Why This Topic Matters
Understanding the review pathway for suspected abuse cases helps readers follow the administrative process, recognize who may be involved in the review, and see where appeal rights and subsequent actions fit into the broader fraud-and-abuse framework.
What You Will Learn
- How abuse integrity reviews may be initiated in a carrier setting
- What roles peer review organizations and medical consultants may play in the review process
- How physician participation and appeal rights fit into the process
- How timing and carrier decision-making may affect the outcome of an abuse review
Who Should Read This
- Medical coders
- Compliance professionals
- Auditors
- Physicians
- Revenue cycle staff
- Fraud and abuse investigators
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