Improper Payments Elimination and Recovery Act: Identifying and Reducing Improper Payments

Posted by IntegrityM | | Medicaid, Medical Claim Review, Medicare

Each year, the Federal Government makes billions of dollars in improper payments. Improper payments can take the form of overpayments, payments to the wrong person, or payments for the wrong reason. Two examples of improper payments include the Federal Government paying $180 million to 20,000 dead individuals over a three-year period, as well as paying…

Network Adequacy: Meeting Requirements and the Impact of the ACA

Posted by IntegrityM | | Consulting, Medicaid, Medicare

The Affordable Care Act directed the Secretary of Health and Human Services to establish criteria for certification of qualified health plans, to include (1) ensuring a sufficient choice of providers and (2) providing information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers.  45 CFR 156.230, entitled network adequacy standards, requires qualified…

Medicaid Health Homes Program Operation

Posted by IntegrityM | | Medicaid, Medicare

Section 2703 of the Affordable Care Act created an optional Medicaid State Plan benefit – Health Homes – to coordinate care for individuals who have Medicaid and have: 2 or more chronic conditions; 1 chronic condition and are at risk for a second; or 1 serious and persistent mental health condition. Chronic conditions include substance…

Medicaid Encounter Data Problems Continue

Posted by IntegrityM | | Government Evaluation, Medicaid

In May 2009, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a report regarding Medicaid managed care encounter data.  The OIG found all 40 States with capitated managed care reported collecting encounter data from their managed care plans. However; 15 States did not include encounter data in their Medicaid Statistical…

Ambulance Billing Fraud and False Claims

Posted by IntegrityM | | Audit, Medicaid, Medical Claim Review, Medicare

Medicare ambulance claims, just like everything involved with Medicare, must meet certain requirements to be considered valid ambulance transport claims. The main factor is the transport must be considered “medically necessary” under Federal Law. To do this, two specific criteria must be met: The use of other transportation methods is contraindicated by the condition of…

Medicaid Dental Fraud, Waste and Abuse Reporting

Posted by IntegrityM | | Audit, Government Evaluation, Medicaid

OIG has just released the last in a series of four Medicaid dental fraud reports.  The reports identified dentists and orthodontists with questionable billing practices in New York, Louisiana, Indiana, and California.  These reports are just one part of OIG’s multi-faceted approach to combat dental fraud.  The agency also has ongoing audits of Medicaid dental…

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