decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Fraud and Abuse / PROs brought in for abuse cases
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Article Overview
This article covers the role of peer review organizations in abuse cases, how a carrier may use medical consultants or special review processes, and how the resulting decisions can affect a physician. It is intended for readers who need a general understanding of fraud-and-abuse workflow, carrier review, and the related appeal pathway. The article also references manual guidance sources that frame these procedures within Medicare administration.
Why This Topic Matters
Understanding how abuse cases are reviewed helps coding, compliance, and appeals personnel recognize the administrative process that can affect payment and provider status.
What You Will Learn
- How peer review organizations may become involved in abuse-related review
- How carrier review and medical consultation may factor into an abuse case
- What general appeal path may follow an unfavorable decision
- Which kinds of procedural guidance the article cites
Who Should Read This
- Medical coders
- Compliance staff
- Billing staff
- Healthcare administrators
- Appeals and audit personnel
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