decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Exclusion / Medicare Contractor Role in Exclusion / Development of potential exclusion cases
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Article Overview
This article covers the Medicare contractor’s role in identifying and developing potential exclusion cases for referral to the OIG under program integrity guidance. It is aimed at coders, compliance staff, auditors, and healthcare administrators who need a high-level understanding of how exclusion referrals are documented and reviewed. The article discusses the general factors considered in case development, the types of case histories that must be established, and the broader documentation expected when quality-of-care or excessive-charge concerns are involved.
Why This Topic Matters
Exclusion actions can affect provider participation, compliance risk, and access to care. Understanding the contractor review framework helps organizations recognize the kinds of documentation and oversight expected in potential exclusion matters.
What You Will Learn
- How Medicare contractors evaluate potential exclusion referrals
- What broad factors are considered when developing exclusion cases
- What general documentation elements support a referral involving alleged overcharging or substandard care
- Why corrective-action history and physician input may be relevant in exclusion case development
Who Should Read This
- Medical coders
- Compliance officers
- Healthcare auditors
- Revenue integrity professionals
- Healthcare administrators
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