Posted and filed under Compliance, FWA, Healthcare, Payers.

The Fraud Spotlight series is a long-form examination of current fraud trends and investigative strategies from our team of retired OIG agents and expert fraud investigators. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes. 

Recently, we discussed a situation where Medicare may still pay for a service, item or procedure when that patient is covered by workman’s compensation, or no-fault, for example. We believe that some of the readers were a bit amazed that scenarios exist when such a situation occurs. Medicare as a Secondary Payer (MSP) can have some complexities and nuances that can cause a practice some havoc. As our blog of the prior week demonstrated, very strong internal billing and compliance is an absolute necessity to avoid a double payment situation.  

Double billing in the traditional sense is something that requires some forethought by an unscrupulous provider, as traditional edits will usually catch same date of service, same diagnosis type schemes. It’s the MSP situations that are more difficult to catch. If Medicare does not know they are the second payor, or if the program doesn’t know that a payment was issued by the primary on an accident type claim, identifying that double payment may be a challenge.  

View “Your guide to who pays first,” by Medicare.  

This link will take our dedicated readers to a document CMS published on some of the various scenarios.  Our point is always from a complaint billing and coding perspective. There is really no justifiable rationale for keeping both a negotiated payment AND a Medicare payment, when said negotiated payment is made to the provider.  Always remember, making that reimbursement back to Medicare is always much cheaper than having to make a self-disclosure, or worse, the hiring of effective counsel in response to an investigation.  

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact our former OIG and Fraud Investigation team by emailing info@advizehealth.com for more information on our Fraud Spotlight series.