The IntegrityM Blog
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 […]
Data Matching Techniques For Healthcare Fraud Detection
Healthcare fraud very seldom happens in a vacuum. Therefore, data matching — the ability to identify, match, and merge records that correspond to the same entities — is essential to healthcare data analysis. Using The NPPES Database For Data Matching The Centers for Medicare & Medicaid Services issues a unique identification number called a national […]
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 […]