decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Medicare Contractor Role in Fraud Enforcement / Contractor Actions to Protect Medicare
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Article Overview
This premium article covers the role of Medicare contractors in detecting and responding to suspected provider fraud. It outlines the kinds of evidence contractors are trained to consider, the general types of contractor actions that may follow, and the organizations involved in referral or enforcement-related review. The content is aimed at coding, compliance, audit, and reimbursement professionals who need to understand Medicare program integrity topics without relying on the full article.
Why This Topic Matters
Medicare program integrity depends on recognizing suspicious billing activity early and responding appropriately. Understanding the contractor perspective helps compliance teams, auditors, and billing staff interpret oversight activity and related Medicare safeguards.
What You Will Learn
- How Medicare contractors evaluate indicators that may suggest fraudulent billing
- What broad categories of evidence can support contractor concern
- How contractor responses fit into Medicare program integrity efforts
- Which types of organizations may be involved in escalation or review
Who Should Read This
- Medical coders
- Compliance professionals
- Billing staff
- Auditors
- Revenue cycle teams
- Healthcare administrators
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