COMPLIANCE: Watch Those Big-Ticket Claims or the OIG Will Watch for You

Why This Topic Matters

High-dollar claims can draw increased audit attention, and billing errors may create refund obligations or denial issues. Understanding the general compliance themes in this article helps practices review claims, monitor payer communications, and recognize when overpayments or edits may be involved.

Article Sections

1. Overview of OIG attention to high-dollar claims

   Introduces the compliance focus on large claims payments and the relationship to audit activity and medically unlikely edits.

2. Examples from recent audit findings

   Summarizes audit findings involving payment discrepancies across multiple claims and service types, illustrating the kinds of issues reviewed in the article.

3. Refunds, denials, and appeals

   Discusses general obligations around identified overpayments, the possibility of appealing denied claims, and the importance of reviewing payer notices.

4. HCPCS and EOB remarks related to MUEs

   Covers a HCPCS modifier and an explanation-of-benefits remark code discussed in connection with medically unlikely edits and claim review.