decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Medicare Contractor Role in Fraud Enforcement / Cases Referred to and Accepted by OIG / Case Summary Format
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Article Overview
This article explains the case summary format Medicare contractors are expected to use when developing and referring suspected fraud matters to the OIG. It outlines the kinds of background, billing, correspondence, and corroborating information that should be collected and organized, and it is relevant to compliance staff, auditors, investigators, and coding or billing professionals involved in program integrity work. The content is administrative and investigative in nature rather than a coding policy update.
Why This Topic Matters
It helps readers understand the scope of information Medicare contractors are expected to compile for fraud case development and referral, which is important for compliance, internal audit preparation, and investigative coordination.
What You Will Learn
- What categories of information Medicare contractors are instructed to include in a fraud case summary
- How complaint source, billing history, and corroborating materials are organized in the referral process
- What background and correspondence details may be gathered during case development
- How related agencies, chain relationships, and prior complaint history can factor into a case file
Who Should Read This
- Medicare contractors
- Compliance officers
- Medical auditors
- Program integrity staff
- Healthcare investigators
- Revenue cycle professionals
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