Posted and filed under Coding, Compliance, Fraud.

Upcoding vs. Downcoding

Physicians and their billing/coding staff have an established history with, and an acute awareness of upcoding and overpayments. In fact, unless they’re operating within a fraudulent billing scheme, they’re avoiding the practice of upcoding all together. Upcoding is arguably the most common red flag in both audit selections and audit results, making it a serious…

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Posted and filed under Fraud, Healthcare.

Are Your Eyes Deceiving You?

Are you being used by your doctor? Do you ever go to your optometrist for a routine eye exam and unknowingly leave with a medical condition? Were you asked for your medical insurance card at your visit? Why is that? Routine eye exams are covered by your vision plan. Most people go for an eye…

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Posted and filed under Coding, Fraud.
pain-management

Chiropractic Billing Red Flags

All insurance payers are obligated to perform routine reviews of claims submitted by providers who operate under their plans. In recent years these claims examinations have gotten more rigorous, with antifraud initiatives being pushed by private health plans and those operating under the umbrella of CMS. The prevalence of insurance fraud has created a hypervigilant…

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Posted and filed under Fraud, Healthcare.

Bad Reputation: Big Pharma’s Eventful Year

Thinking back to late 2015, the pharmaceutical industry was shaken by a tsunami of criticism and vitriol, all thanks to the rapacity of Big Pharma “bad boy” Martin Shkreli. You may recall Shkreli’s ill-received decision to jack up the price of Daraprim from $13.50 a pill, to an inconceivable $750 per pill only one month…

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Posted and filed under Compliance, Fraud, Healthcare.

Healthcare’s Data Vulnerability Problem

A study conducted by three universities has revealed a fatal flaw in the healthcare industry’s cyber security operations – lack of cohesion between cyber security protocol and the proper execution of such procedures. Healthcare organizations are vulnerable to data breaches because cyber security efforts are perceived as an interruption of clinical workflow, rather than as…

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Posted and filed under Fraud, FWA.

Fraud Waste and Abuse Fact – October

Whistleblower Lawsuit Leads to Record Setting Settlement for Adventist Health System Adventist Health System will pay $118.7 million to the federal government and four states to settle a whistleblower lawsuit filed in December 2012. The lawsuit alleged that Adventist paid doctors excessive compensation for patient referrals to Adventist-owned health care facilities, including hospitals, clinics and…

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