decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Medicare Contractor Role in Fraud Enforcement / Administrative Sanctions / Exclusion
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Article Overview
This article covers Medicare contractor involvement in fraud enforcement, administrative sanctions, and exclusion decisions. It focuses on how benefit integrity staff review abuse cases, the types of provider conduct that may trigger consideration of exclusion, and the kinds of outside medical review sources that can support those determinations. The content is aimed at coding, compliance, and program integrity professionals who need a high-level understanding of exclusion-related contractor processes.
Why This Topic Matters
Understanding contractor review and exclusion-related processes helps compliance and program integrity teams recognize when a case may escalate beyond routine billing oversight and what review resources may be used in support of that process.
What You Will Learn
- How Medicare contractors participate in fraud enforcement and exclusion-related case review.
- What categories of provider conduct may be evaluated for possible exclusion.
- Which external review entities may be consulted during medical determination review.
- How benefit integrity units fit into the exclusion review process.
Who Should Read This
- Medical coders
- Compliance professionals
- Program integrity staff
- Revenue cycle teams
- Provider billing staff
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