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 p...
Medicare Overpayment Recovery: Identifying and Calculating Overpayments
In fiscal year (FY) 2015, the error rate for the Medicare fee-for-service (FFS) program was 12.1 percent, or $43.3 billion. This result is an improvement over FY 2014, in which Medicare FFS had an improper payment rate of 12.7 percent, or $45.8 billion.
Identifying Medicare ...
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 ...
GLȲD(Σ): Revolutionizing Healthcare Data and Statistical Analysis
What if there was a healthcare data analysis solution that could save you a significant amount of time in the sampling and extrapolation process, resulting in substantial cost savings, and therefore greatly increasing your return on every dollar invested into this process? M...
Network Adequacy: Meeting Requirements and the Impact of the ACA
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 ...
Using the CIGIE Quality Standards for Inspection and Evaluation
It is important for every industry to have a framework of quality standards by which to measure performance and to establish credibility. Most people have heard of the Yellow Book, or The Generally Accepted Government Auditing Standards, that is used by audit organizations. ...
How Effective are Criminal Background Checks Really?
A U.S. Department of Health and Human Services Office of Inspector General (OIG) report from October, 2012 offers some interesting insights into the usefulness of criminal background checks for nurse aides. To get to these insights, some setup is needed.
Nurse aides work in ...
Medicaid Health Homes Program Operation
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 pers...
Healthcare Secret Shopping: An Effective Tool for Detecting Fraud and Abuse
The Government Accountability Office (GAO) made headlines recently when sharing news that 11 of 12 fictitious applicants obtained coverage for health insurance through the Federal marketplace. GAO targeted the Federal marketplace with secret shopping – constructing fictitious...
Medicaid Encounter Data Problems Continue
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 car...
