decisionhealth Newsletters, Part B News - 2015 Issue 11 (November)
When claims audit looks bound for the DOJ, act first to avoid penalties
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Article Overview
This article explains when a billing audit or suspected overcoding issue may move beyond a Medicare contractor review and attract scrutiny from OIG or the DOJ. It is aimed at compliance, billing, and coding professionals who want to understand the general factors that can increase enforcement risk, the role of self-disclosure, and the broad reporting pathways mentioned in the article.
Why This Topic Matters
Understanding how potential billing concerns can progress helps organizations assess compliance risk, decide when to involve counsel, and recognize the importance of timely internal review and voluntary reporting.
Article Sections
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Compliance
Introduces the article’s focus on billing compliance concerns and the possibility of escalation beyond routine contractor review.
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When the feds tune in
Summarizes factors discussed as influencing whether a case moves from contractor review to federal enforcement attention, including broader investigative and compliance considerations.
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Turn yourself in
Describes the article’s discussion of voluntary reporting options, including the general distinction between contractor-level resolution and escalation to federal authorities.
What You Will Learn
- How billing concerns may be noticed and escalated within the Medicare oversight process.
- What broad factors may increase the likelihood of federal attention to a billing issue.
- What general self-disclosure and reporting pathways are discussed for potential compliance problems.
- Why legal and compliance consultation is emphasized when a problematic pattern is identified.
Who Should Read This
- Medical coders
- Billing staff
- Compliance officers
- Practice administrators
- Healthcare attorneys
- Revenue cycle professionals
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