Picture yourself balancing on top of a fence with vast expanses of land, each with their own set of governance, visible to you from both sides. You’re straddling the fence, your legs occupying each of the divided spaces. Where do you stand? It depends on which way the wind blows. Such is the case with…
Advize Health had the honor of attending NHCAA’s Annual Training Conference (ATC) in Atlanta, GA earlier this month. The ATC is widely-regarded as the most important assembly against healthcare fraud, where attendees explore fraud schemes, trends, and best practices for identification, investigation, and prosecution of fraud-related offenses. The conference, which was in operation over the…
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…
Last week, Advize Health returned to Florida after fighting fraud in Baltimore during NAMPI 2016. This annual National Association for Medicaid Program Integrity took place from August 28-31st, and was held at the Baltimore Marriott Waterfront Hotel. This conference offered more than waterfront views and famous Baltimore cuisine. Jeanmarie Loria, Advize Health’s Managing Director and…
Advize Health will take you step by step through several real life audit example from data selection to extrapolations and recoveries. Find out common pitfalls and areas of your policies and procedures that could be tighten up to guard against FWA. We will present the differences between a postpayment audit and a prepayment audit and…
Stringent billing guidelines and regulations are often instituted to limit the incidence of fraud, waste, and abuse (FWA). Specificity increases annually, providing a well-developed outline for physicians and billers. Revisions to billing procedures are designed to help all facets of the healthcare industry. An example is incident-to billing, which was introduced to address the trend…
A major case of criminal activity has made its way to the courts, and is a prime example of the importance of auditing medical records. The work of auditors focusing on fraud, waste, and abuse may often be overlooked by many in the healthcare field – but in many cases, auditors are champions for the…
There are many techniques to extracting data that can range from reviewing claim line billing data to actual medical record reviews. Relying exclusively on the claims data to analyze and identify atypical billing patterns or potential red flags is always challenging. As auditors we all know that the value of the audit process is only…
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…
Affordable Care Act Fraud Criminals Facing Tougher Sentences Due to the Affordable Care Act, criminals convicted of fraud now face tougher sentences and more jail time. Criminals will receive 20 to 50 percent longer sentences for crimes that involve more than $1 million in losses. “The government’s successes in prosecuting and winning health care fraud…