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Spotlight on February 2025 FWA

Auditing

Spotlight on February 2025 FWA

Man Pleads Guilty in Connection With $17M Medicare Hospice Fraud and Home Healthcare Fraud Schemes 

 

A California man pleaded guilty to healthcare fraud, aggravated identity theft, and money laundering in connection with a years-long scheme to defraud Medicare of more than $17 million through sham hospice companies and his home healthcare company. According to court documents, this man engaged in a scheme with others to operate a series of sham hospice companies. He, along with co-schemers, impersonated the identities of foreign nationals to use as the purported owners of the hospices—including using the identities to open bank accounts and sign property leases—and submitted false and fraudulent claims to Medicare for hospice services that were not medically necessary and not provided.

 

In submitting the false claims, he and his co-schemers also misappropriated the identifying information of doctors, claiming to Medicare that the doctors had determined hospice services were necessary, when in fact the purported recipients of these hospice services were not terminally ill and had never requested nor received care from the sham hospices. As a result of the scheme, Medicare paid the sham hospices nearly $16 million. The man personally received nearly $7 million of the proceeds from the fraud scheme, including more than $5.3 million in transfers to his personal and business bank accounts, which were laundered through a dozen shell and third-party bank accounts. He additionally admitted to wrongfully obtaining more than $1 million for his home healthcare agency through the fraudulent use of a doctor's name and identifying information in certifying Medicare beneficiaries for home healthcare, which he attempted to cover up by paying the doctor $11,000.

 

He pleaded guilty to healthcare fraud, aggravated identity theft, and money laundering. He is scheduled to be sentenced and faces a mandatory penalty of two years in prison on the aggravated identity theft charge, a maximum penalty of 10 years in prison on the healthcare fraud charge, and a maximum penalty of 20 years in prison on the money laundering charge. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

 

Source: Man Pleads Guilty in Connection With $17M Medicare Hospice Fraud and Home Health Care Fraud Schemes (2025, February 3). www.justice.gov

 

Pharmacy LLC Agrees to Resolve False Claims Act Allegations of Billing for Drugs Not Dispensed 

 

A New Jersey pharmacy has agreed to pay $350,000 to resolve allegations that it violated the False Claims Act by knowingly billing a federal healthcare program for certain medications that it never dispensed. According to the contentions of the United States in the settlement agreement: The United States alleged that, from January 1, 2015, through February 27, 2023, the pharmacy caused the submission of claims for reimbursement to the Medicare Part D Program for certain drugs that were never dispensed to beneficiaries. The government contends that inventory records showed that the pharmacy did not purchase enough of these medications from wholesalers to fill the prescriptions billed to the federal healthcare program.

 

The claims settled by the agreement are allegations only, and there has been no admission of liability.

 

Source: Pharmacy LLC Agrees to Resolve False Claims Act Allegations of Billing for Drugs Not Dispensed (2025, February 4). www.justice.gov

 

Louisiana Doctor Sentenced for Illegally Distributing Over 1.8M Doses of Opioids in $5.4M Healthcare Fraud Scheme

 

A Louisiana physician was sentenced yesterday to 87 months in prison for conspiring to illegally distribute over 1.8 million doses of Schedule II controlled substances, including oxycodone, hydrocodone, and morphine, and for defrauding healthcare benefit programs of more than $5.4 million.

 

According to court documents and evidence presented at trial, the physician owned and operated Medex Clinical Consultants (Medex). Medex was a medical clinic that accepted cash payments from individuals seeking prescriptions for Schedule II controlled substances. The physician routinely ignored signs that individuals frequenting Medex were drug-seeking or abusing the drugs prescribed. In 2015, the physician took a full-time job elsewhere, and although he was no longer physically present at the clinic, he pre-signed prescriptions, including for opioids and other controlled substances, to be distributed to individuals there whom he did not see or examine. In 2016, he hired another practitioner who, at his direction, also pre-signed prescriptions to be distributed to individuals in exchange for cash deposited into a Medex bank account. The evidence also demonstrated that the physician falsified patient records to cover up the scheme and to make it appear as though he was routinely examining the patients. With his knowledge, these individuals filled their prescriptions using their insurance benefits, thereby causing healthcare benefit programs, including Medicare, Medicaid, and Blue Cross Blue Shield of Louisiana, to be fraudulently billed for controlled substances that were prescribed without an appropriate patient examination or determination of medical necessity.

 

On July 22, 2024, the physician was convicted by a jury in the Eastern District of Louisiana of one count of conspiracy to unlawfully distribute and dispense controlled substances, four counts of unlawfully distributing and dispensing controlled substances, one count of maintaining a drug-involved premises, and one count of conspiracy to commit healthcare fraud.

 

Source: Louisiana Doctor Sentenced for Illegally Distributing Over 1.8M Doses of Opioids in $5.4M Health Care Fraud Scheme (2025, February 6). www.justice.gov

 

Four Pharmacists Sentenced for Roles in $13M Medicare, Medicaid, and Private Insurer Fraud Conspiracy

 

Four pharmacy owners have been sentenced for their roles in a conspiracy to commit healthcare fraud and wire fraud. One was sentenced to 10 years in prison; the second to seven years in prison; the third to two years in prison; and the fourth pharmacist was sentenced to five years and five months in prison.

 

According to court documents and evidence presented at trial, they billed Medicare, Medicaid, and Blue Cross Blue Shield of Michigan for prescription medications that they did not dispense at five pharmacies they owned and operated in Michigan and Ohio. The defendants collectively caused over $13 million of loss to Medicare, Medicaid, and Blue Cross Blue Shield of Michigan.

 

On September 5, 2024, a federal jury convicted all four of conspiracy to commit healthcare fraud and wire fraud.

 

Source: Four Pharmacists Sentenced for Roles in $13M Medicare, Medicaid, and Private Insurer Fraud Conspiracy (2025, February 6). www.justice.gov

 

Doctor Convicted of $24M Medicare Fraud Scheme

 

A New York doctor was found guilty by a federal jury for causing the submission of over $24 million in fraudulent claims to Medicare for medically unnecessary laboratory tests and orthotic braces. According to court documents and evidence presented at trial, the physician received tens of thousands of dollars in illegal cash kickbacks and bribes in exchange for ordering laboratory tests, including expensive cancer genetic tests, that were billed to Medicare by two related laboratories located in New York.

 

As part of the scheme, he authorized hundreds of cancer genetic tests for Medicare beneficiaries who attended COVID-19 testing events at assisted living facilities, adult day care centers, and a retirement community in 2020. The physician was not treating any of the patients who attended the testing events and, in many cases, did not speak to or examine the patients prior to ordering cancer genetic tests and other laboratory tests for them. He also billed Medicare for lengthy office visits that he never provided to these patients. Several Medicare patients for whom he ordered cancer genetic tests and billed for office visits testified at trial that they did not know who he was and had never met or spoken to him. The physician did not contact the patients after the testing events to review the results of the cancer genetic tests, and, in some cases, the patients never received the test results.

 

In addition to the laboratory testing scheme, he also received illegal cash kickbacks and bribes from the owner of a durable medical equipment supply company in exchange for ordering medically unnecessary orthotic braces for Medicare and Medicaid beneficiaries. The evidence presented at trial showed him on an undercover video receiving a large sum of cash in exchange for signed prescriptions for orthotic braces.

 

The medically unnecessary laboratory tests and orthotic braces that he ordered in exchange for illegal kickbacks and bribes caused Medicare to be billed more than $24 million. Medicare paid more than $2.1 million to the laboratories and the durable medical equipment supply company involved in the schemes.

 

Following his conviction on the 10 counts, he was remanded to the custody of the U.S. Marshals Service. He is scheduled to be sentenced on June 26 and faces a maximum penalty of 10 years in prison on each count of conspiracy to commit healthcare fraud, healthcare fraud, and solicitation of healthcare kickbacks, and five years in prison on each count of conspiracy to defraud the United States and to pay, offer, receive, and solicit healthcare kickbacks and conspiracy to defraud the United States and to receive and solicit healthcare kickbacks. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

 

Source: Doctor Convicted of $24M Medicare Fraud Scheme (2025, February 11). www.justice.gov

 

Vice President of Healthcare Software and Services Company Pleads Guilty to $1B Healthcare Fraud Conspiracy

 

A Kansas man pleaded guilty to operating an internet-based platform that generated false doctors' orders to defraud Medicare and other federal healthcare benefit programs of more than $1 billion.

 

According to court documents, the man admitted that he and his co-conspirators targeted hundreds of thousands of Medicare beneficiaries to provide their personally identifiable information and agree to accept medically unnecessary orthotic braces, pain creams, and other items through misleading mailers, television advertisements, and calls from offshore call centers. He and his co-conspirators owned, controlled, and operated DMERx, an internet-based platform that generated false and fraudulent doctors' orders for orthotic braces, pain creams, and other items for these beneficiaries. As the vice president of the company that operated DMERx, he admitted that he offered to connect pharmacies, durable medical equipment (DME) suppliers, and marketers with telemedicine companies that would accept illegal kickbacks and bribes in exchange for signed doctors' orders that were transmitted using the DMERx platform. He and his co-conspirators received payments for coordinating these illegal kickback transactions and referring the completed doctors' orders to the DME suppliers, pharmacies, and telemarketers that paid for them. The fraudulent doctors' orders generated by DMERx falsely represented that a doctor had examined and treated the Medicare beneficiaries when, in reality, purported telemedicine companies paid doctors to sign the orders without regard to medical necessity and based only on a brief telephone call with the beneficiary, or sometimes no interaction with the beneficiary at all. The DME suppliers and pharmacies that paid illegal kickbacks in exchange for these doctors' orders generated through DMERx billed Medicare and other insurers more than $1 billion. Medicare and the insurers paid more than $360 million based on these false and fraudulent claims.

 

He pleaded guilty to conspiracy to commit healthcare fraud and faces a maximum penalty of 10 years in prison. A sentencing hearing will be scheduled at a later date. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

 

Source: Vice President of Health Care Software and Services Company Pleads Guilty to $1B Health Care Fraud Conspiracy (2025, February 20). www.justice.gov

 

Ohio Doctor Agrees to Pay $600,000 to Settle False Claims Act Allegations 

 

An Ohio physician has agreed to pay the United States $600,000, plus contingent payments, to resolve False Claims Act allegations that he submitted fraudulent Medicare claims related to electro-acupuncture devices. This man is a doctor licensed in Ohio who provided electrical nerve pulse stimulation services to patients in facilities across the state. From 2016 until 2018, he allegedly improperly billed Medicare for the application of percutaneous electrical nerve pulse stimulation devices (the “P-Stim Device”) in an office setting. The P-Stim Device is a device for treatment of chronic pain that, per the manufacturer's instructions, is affixed behind a patient's ear using an adhesive. Needles are inserted into the patient's ear and affixed using another adhesive. Once activated, the device then provides intermittent stimulation by electrical pulses. It is a single-use, battery-powered device designed to be worn for several days until its battery runs out, at which time the device is thrown away.

 

The procedures allegedly did not involve any surgery, anesthesia, or take place in an operating room (or even at a facility with such capabilities) but were billed to Medicare as surgically implanted neurostimulators, contrary to repeated guidance from the Centers for Medicare & Medicaid Services.

 

Source: Ohio Doctor Agrees to Pay $600,000 to Settle False Claims Act Allegations (2025, February 21) www.michigan.gov

 

Source: Sonal Patel, BA, CPMA, CPC, CMC, ICDCM 

 

Sonal Patel is CEO and Principal Strategist at SP Collaborative and has over 13 years of experience understanding the art of business medicine. She is a nationally recognized thought-leader, speaker, author, creator, and consultant. As the CEO and Principal Strategist of SP Collaborative, LLC, she serves as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical coders, auditors, and compliance professionals in working together to elevate coding compliance education for the business of medicine. 

 

www.spcollaborative.net

 

 

Types of Healthcare Audits

Auditing

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Auditing

CMS Report Highlights Complaints and Enforcement Actions Under the No Surprises Act:This week, the Centers for Medicare and Medicaid Services (CMS) released a report detailing complaints and enforcement actions related to the Public Health Service Act, which encompasses the No Surprises Act.
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Auditing

Enterprise-Based Denial Management: A Comprehensive Approach:With denied claims rising – up 10.15% in 2020, 11.2% in 2022, and then 11.99% in 2023 (according to Fierce Healthcare) – it is clear that healthcare organizations face an escalating challenge that demands a comprehensive, thorough strategy.
Auditing Surgical Services

Auditing

Auditing Surgical Services:While E&M auditing continues to be the industry favorite for professional medical auditors in this field, there are several reasons and opportunities to audit surgical services.
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Auditing

California Made Capitation Payments for Enrollees Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Another State:California pays managed care organizations to make services available to eligible Medicaid enrollees in return for a monthly fixed payment (capitation payment) for each enrollee.
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Auditing

Auditing the Global Package:When auditing provider services, what is the best method to approach the concept of a global package? Some rental companies provide a renter with all-inclusive pricing for an apartment. The payment arrangement covers heating, electricity, water, and garbage for the one-bedroom apartment.
Modernizing Auditing and Compliance in Healthcare

Auditing

Modernizing Auditing and Compliance in Healthcare:The Importance of Auditing - Regular auditing of medical charts and coding documentation is indispensable for identifying errors, ensuring regulatory compliance, and reducing the risk of fraud. Audits not only uncover coding inaccuracies but also offer valuable insights into areas for improvement within the organization's processes and procedures.
Monthly Spotlight on Fraud, Waste, and Abuse

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Monthly Spotlight on Fraud, Waste, and Abuse:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.
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HHS Modifies Rule for Confidentiality of Substance Use Disorder Records - HHS Issues Final Rule:On February 8, 2024, the Department of Health and Human Services (HHS) announced that it had approved the modification of rules regarding the confidentiality of patient Substance Use Disorder (SUD) records. After careful consideration of public comments, the HHS determined that approval of the Final Rule would improve coordination of care, and, ultimately, the quality of patient care.
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Monthly Spotlight on Fraud, Waste, and Abuse:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.
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AI Auditing: Walking Backward Toward Home:Way back in 1976, as an elementary school kid in the suburbs of Philadelphia, I came across a book in the library called 2010: Living in the Future. In my then-current world of AMC Pacers and seersucker suits, the book promised great things.
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Auditing

Monthly Spotlight on Fraud, Waste, and Abuse:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services. 
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Auditing

The Audit Process :I hold a LinkedIn Live broadcast called Health Care Happenings that also airs on Facebook and YouTube every other Thursday, in which I discuss different healthcare topics.  I recently did a three-part series on auditing: Preparing for the Audit, Performing the Audit, and Providing the Audit Results.  This article will expand on that series to discuss the audit process.
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Auditing

Maximize Duplex Doppler Ultrasound Documentation and Reimbursement:Complete documentation of any radiology procedure is the key to appropriate reimbursement.  This is especially true for venous duplex Doppler ultrasound exams, where including fewer than the required number of elements for a complete procedure will result in reimbursement for a limited study.  
Monthly Spotlight on Fraud, Waste, and Abuse

Auditing

Monthly Spotlight on Fraud, Waste, and Abuse:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services. 
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Auditing

Monthly Spotlight on Fraud, Waste, and Abuse - August 2023:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services. 
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Auditing

If Conduct Appears to Buck the Legal Norm, Chances Are That It Does:It's akin to wearing Doc Martens to a professional cocktail party reception or Uggs to court. In other words, the wardrobe choice jumps out as not being appropriate for the situation. Likewise, certain conduct that violates the Anti-Kickback Statute (AKS) and the False Claims Act (FCA) unequivocally jumps out as being unlawful under the facts and circumstances, yet persons engage in the inappropriate behavior. 
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Auditing

As CMS Focuses on Quality, There Are Monumental Changes to Reimbursement for Quality on the Horizon!:The Centers for Medicare and Medicaid Services (CMS) utilizes risk adjustment factors to estimate the cost of Medicare Advantage (MA) beneficiaries and those associated costs of providing care.  Risk adjustment factor scores govern the amount paid by the health plan during the year for the beneficiary's care.  
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Auditing

Choosing the Right Tool: Targeted vs. Random E/M Audits:The realm of E/M (evaluation and management) auditing is vast, and 2023 will bring more work here than before thanks to CPT's extensive revisions to its E/M guidelines for inpatient, facility, and home visit services - now in effect. Both compliance professionals and providers must always keep in mind that E/M services (which account for a third of annual Medicare Part spending) will go from being a perennial easy target to an urgent area of attention in 2023.
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Auditing

Who Can It Be Knocking at Your Door? Are You Prepared? :The truth is, you can never be fully prepared when a Special Investigative Unit (SIU) from Medicare or Medicaid shows up unannounced.
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Auditing

Self-Audits:Self-audits are critical. They demonstrate compliance, or at least a "good-faith effort" to be compliant; they minimize refunds of overpayments to "actuals" and also mitigate the potential for a multiple being added.
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Auditing

Provider Education: The Most Important Step of the Audit Process:You've taken the time to complete a painstaking audit of a provider, combing through their documentation on an EHR or maybe even navigating through a handful of handwritten notes. 
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Auditing

Modifier 25 Pre-Bill Review: Were You Ready?:After all the hype surrounding the upcoming Cigna policy regarding modifier 25 and pre-bill reviews, it seems as if Cigna is not planning on implementing the policy as planned on August 14, 2022.
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Auditing

Navigating the UPIC Investigation from a Compliance Consultant's Perspective:Over the past year and a half, I have seen a significant increase in the volume of Unified Program Integrity Contractor (UPIC) investigations taking place in private physician practices. 
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Auditing

Culture in Compliance:For years, we have talked about the culture in healthcare, especially for compliance purposes, but for many practices, that culture takes a backseat despite continued guidance.
2022 Annual Audit Elements: What Should Be Reviewed

Auditing

2022 Annual Audit Elements: What Should Be Reviewed:Four months into 2022 and the question is: How far along is your audit of high, medium, and low-risk services? If you are like most practices or health systems, something always gets in the way and causes audits to take a back seat.
Should Your 2022 Audit Plan Include Paid Claims?

Auditing

Should Your 2022 Audit Plan Include Paid Claims?:In 2022, when we sit down to configure an audit plan, we often consider whether we will perform an audit retrospectively or prospectively, and whether the sample will include evaluation and management (E&M) services, procedures, or some combination of them both. 
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Auditing

Don't Sleep On Small Claims Denials:Are you ever tempted to just sweep those small claims denials under the rug? Do you sometimes wonder if it is worth the time and effort to figure out why a code, which will end up yielding $30, is being denied? Does it feel like it takes years to understand a denial and find a solution - leaving you to question if you really know what you are doing? I've had many of those moments.
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Auditing

Auditing Infusions, Hydrations, and Injections:If your facility and/or practice is providing infusion, hydration, and injection services, they should be included in your annual compliance auditing plans to ensure proper coding guidelines are being followed and documentation education is not necessary to assist with any loss of revenue gaps.
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Auditing

Ciox: Not a Bleach, But Not to Be Ignored:In my role as a compliance consultant specializing in carrier audit response, a lot of items are brought to my attention on a daily basis, with the bearer of said items asking questions 
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Auditing

Acute Uncomplicated vs Complicated Illness or Injury:When selecting Number and Complexity of Problems Addressed, the complication of treatment required should not be considered. The Risk of Complications of Patient Management is where the treatment options are considered in code selection.
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Auditing

Getting Serious About Compliance:By now, most health systems, practices, and providers should know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan since the passage of the patient Protection and Affordable Care Act in 2010. 
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Auditing

As Pandemic Eases, OIG Ramps Up Audits:With Americans having widespread access to effective vaccines, the COVID-19 pandemic is finally fading into the background for most practices, but the issue of compliance is once again rearing its multi-faceted head.
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Auditing

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Auditing

OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment:According to an Office of The Inspector General Report, the Centers for Medicare & Medicaid Services (CMS) estimate that 9.5% of all payments to Medicare Advantage organizations are improper due to unsupported diagnoses submitted by the organizations themselves. 
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Auditing

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Auditing

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Auditing

The Year of the Audit: Stand Your Ground with Payers:Over the years I have worked with so many wonderful and talented auditors and professionals at Blue Cross Blue Shield payers, UHC, Aetna, CIGNA, Humana, Medicare carriers, etc.
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Auditing

2021 E and M Changes - Diagnoses in the MDM :
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Auditing

It is My Organization: I Can Do What I Want:The age-old question of Can we offer cash-pay discounts, professional courtesy and/or the waiver of co-payments or deductibles continues to be as relevant today as it was 2-decades ago.
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Auditing

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Auditing

OIG Compliance 101 - Ensuring the Next Generation is Prepared:
Each day our industry gains new members who are eager to learn and make a difference in the organizations in which they work.
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Auditing

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Auditing

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Auditing

Medical Necessity and The False Claims Act:With so many things to consider regarding why compliance needs to be established 
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Auditing

Auditing for Reimbursement:
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Auditing

Joint Commission and the Value of Accreditation:Around the world accreditation is used to assure a high baseline level of healthcare quality. In the United States, accreditation is a multi-million-dollar industry without any sign of slowing down because it's compulsory for federal payments and a marketing necessity in an increasingly competitive landscape.
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Auditing

New DOJ Guidance on Evaluating Corporate Compliance Programs:The DOJ's guidance document sets forth topics and questions to address three fundamental questions that prosecutors ask when evaluating compliance programs to guide its investigation:
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Auditing

You CAN Charge Medicare More Than You Charge Some Patients:there is no governmental requirement that a clinic have a uniform charge for all payers
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Auditing

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Auditing

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Auditing

OIG Compliance 101 - Ensuring the Next Generation is Prepared:Each day our industry gains new members who are eager to learn and make a difference in the organizations in which they work.
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Auditing

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Auditing

Extrapolation Policies Apply to RADV Audits:Risk Adjustment is a program that was implemented to identify and support Medicare
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Auditing

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Auditing

Small Breaches Can Be Subject to Large Penalties :We may have heard about the large fines issued by the Office for Civil Rights
HIPAA Changed    Again  Are You Compliant

Auditing

HIPAA Changed Again Are You Compliant:The most common violations that providers encounter will occur under Tier One or Tier Two.
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Auditing

Conducting a Fraud Investigation Part 1 Taking a Common Sense Approach:I thought I would create a post that would really ensure understanding
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Auditing

Auditing Hospitalist Services:The inpatient side of coding and auditing can be enormously complex
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Auditing

I Know What We’re Doing is Wrong I Need My Paycheck:Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment
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Auditing

An Update on the DHS OIG's Effort to Combat Fraud & Abuse:The fall edition of the Semiannual Report to Congress covers OIG activities
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Auditing

Understanding Prepayment Audit Reviews:Being placed on prepayment audit review is extremely frustrating for a physician
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Auditing

What Do You Need to Know About Contact from a Federal Agent:Here are some basic principles everyone should know
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Auditing

The Myth about Pass Fail Rates for Providers:leadership wants a general idea of what their compliance risk looks like
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Auditing

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Auditing

Auditing Ophthalmology and Optometry Exams:Having this knowledge in your pocket allows you to have a great opening discussion
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Auditing

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Auditing

Overview of AMAs E&M Revisions for 2021:The AMA is allowing comments for reconsideration until midnight Central Standard Time on Monday
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Auditing

Prolonged Services :I find in my own audit reviews that the prolonged service code set is often mistreated
Voluntary Repayments

Auditing

Voluntary Repayments:cShould you volunteer to repay money from Medicare or other federal healthcare programs
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Auditing

How to Correctly Unbundle NCCI Code Pair Edits:An NCCI code pair consists of two codes representing procedures
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Auditing

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Auditing

Revenue Cycle Management Considerations for Auditors:By analyzing key elements and reviewing applicable guidelines
Attestations  Teaching Physicians vs  Split Shared Visits

Auditing

Attestations Teaching Physicians vs Split Shared Visits:The only difficulty will be trying to find out if your commercial payers decide to follow CMS
Medical Necessity vs Documentation for Inpatient Services

Auditing

Medical Necessity vs Documentation for Inpatient Services :Many of the notes we are provided for review include so much information
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Auditing

Medical Student Documentation CMS Relaxing of the Rules:Medicare Claims Processing Manual to allow the teaching physician 
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Auditing

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Auditing  looking between the lines

Auditing

Auditing looking between the lines:When given the task of auditing a group of charts
Billing 99211 Its not a freebie

Auditing

Billing 99211 Its not a freebie:It seems like a simple code to bill
Using a Billing Company versus Hiring a Biller When Starting a Medical Practice

Auditing

Using a Billing Company versus Hiring a Biller When Starting a Medical Practice:The option I do not recommend is the option that requires hiring a biller.
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Auditing

We've Always Done It This Way and Other Challenges in Education:This is one sentiment that we all have had at one time
Prolonged Services  Its Not Just About Time

Auditing

Prolonged Services Its Not Just About Time:One way of looking at this is to take note of the threshold times 
When to Use Modifier 25 and Modifier 57 on Physician Claims

Auditing

When to Use Modifier 25 and Modifier 57 on Physician Claims:it is important to know the distinctions between these two modifiers.
Getting the Right Eligibility Information for Payment  Your Rights and Health Plans Requirement

Auditing

Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement:We need timely and accurate patient information to bill health plans and receive appropriate payment.
Ensure Personal Quality An Auditor's Approach to Research

Auditing

Ensure Personal Quality An Auditor's Approach to Research:We often associate research with a large amount of time
The Importance of Policies

Auditing

The Importance of Policies:With a growing awareness of just how many organizations do not have published policies
Auditing Incident to Services

Auditing

Auditing Incident to Services:Incident to billing offers two key benefits
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?

Auditing

Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?:Are you stumped by billing guidelines for provider based facilities
Auditing Therapy Evaluation Codes  Not So Quick

Auditing

Auditing Therapy Evaluation Codes Not So Quick:New evaluation codes for physical therapy
TKAs to Outpatient  What We Have Learned with Q1

Auditing

TKAs to Outpatient What We Have Learned with Q1:The release of the 2018 Final Rule for the Outpatient Prospective Payment System
The Devil is in the Data Details

Auditing

The Devil is in the Data Details:As an auditor who has reviewed thousands and thousands of encounter documents for level of service
Critical Care Documentation

Auditing

Critical Care Documentation:Critical care documentation should showcritical need for the patient AND immediate action by the provider.

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