Fraud

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Alphabet Soup for Waste and Fraud Inspectors

The following are some of the acronyms you would need to know when communicating with auditors:

National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice.

Medically Unlikely Edits (MUE):  Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code.

Health Care Fraud Summary 2012

The annual report of The Department of Justice Health Care Fraud and Abuse Control Program was issued in February 2013. The executive summary included the following statistics:

    Monetary Results

Fee Resources (Resource 171)

The establishment of appropriate fees for services is one of the greatest challenges in health care. You need to understand the following concepts:

Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  

The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contains information about each zone as well as activity and updates in those regions. 

It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. According to a Forbes article, a health care actuary estimated that private insurers annually “lose perhaps 1 to 1.5 percent in fraud.” Meanwhile, the problem is worse for public insurers. The same actuary estimates that “Medicare and Medicaid may be closer to 10 to 15 percent.” According to the recently released Medicare Fee-for-Service 2013 Improper Payment Rate Report, the improper payment rate increased from 8.5% in 2012 to 10.1% in 2013.

Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 defendants were convicted of health care fraud-related crimes during the year.

Cyber Insurance? What kind of Insurance Policy it that?

Due to the increase of medical transactions stored online and in the cloud, cyber intrusions will only increase. Cyber insurance also known as privacy and network security insurance can help cover the costs incurred if your computer system is compromised, or after a data breach which can include a HIPAA breach. Keep in mind breach notification is legally mandated in 47 states and regulations vary state by state to be sure you are aware of your states laws.

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