Did you know that nurses don’t just defend public health through direct patient care – they’re also crucial team members on the front lines fighting fraud, waste and abuse? Their knowledge represents an irreplaceable asset in any solid medical review team. Medical review is the clinical review of health records, medical bills and supporting data….
Medical Claim Review
How to Write an Effective Healthcare Fraud Investigative Report
A well-written healthcare fraud investigative report can help to identify and prevent improper payments – having a significant impact on individuals and organizations, including federal and state government agencies. The regulations and requirements that govern the healthcare industry are complicated, creating a long and technical process for investigating potential fraud, waste, and abuse. Investigative reports…
Red Flags: Fraud Schemes in Ophthalmology Services
According to the National Eye Institute, by 2050, the estimated number of people with age-related macular degeneration (AMD) in the United States is expected to more than double from 2.07 million to 5.44 million. With the influx of patients expected and healthcare expenditures nearing 18% of the U.S. gross domestic product (GDP) — an estimated…
Efficiently Evaluating “Big Data” for Medicare Fraud Detection
With over 2 billion Medicare claims available for analysis since 2006, the term “Big Data” has no better application than in the health care industry. The opportunity for meaningful analyses resulting from big data is limitless. However, finding the best method for combing through Medicare claims data in an efficient manner can be tricky since…
Five Things to Know About Federally Qualified Health Centers (FQHCs)
Federally Qualified Health Centers (FQHCs) provide primary care services to millions of people each year with limited access to care. Medicare Part B has covered FQHC services at certified FQHCs since 1991. They are an important and very unique part of the Medicare and Medicaid benefits with specific billing and payment rules that can get…
The Benefits of Statistically Valid Random Sampling and Extrapolation for Health Care Audits and Investigations
When performed correctly, statistically valid sampling and extrapolation can be a powerful tool, allowing for the effective use of audit and investigative resources. Statistically valid sampling allows organizations to collect information about a particular universe for a relatively low cost. Rather than incurring the time and expense of reviewing the entire universe, the conclusions drawn…
A Guide to Building a Robust Medical Review Team
Constructing a solid medical review team requires the successful networking, staffing, management, and ongoing support of the clinicians and the support team. The Significance of a Solid Team Medical review is the clinical review of medical records and supporting data in order to provide claims determinations and ensure that payment is made only for services…
Demystifying Medicare Prepayment and Postpayment Claim Reviews
Medicare and other health plans have a variety of tools at their disposal to prevent and identify improper payments. The tools can differ depending on whether they are applied before claims are paid (prepayment review), or after claims are paid (postpayment review). Pre and postpayment reviews are both important program integrity strategies, and can make…
Improper Payments Elimination and Recovery Act: Identifying and Reducing Improper Payments
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…
Ambulance Billing Fraud and False Claims
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…
