by Advize Admin | Mar 25, 2022 | Compliance
Providers are most often paid in Fee-For-Service (FFS) models for visits AFTER they occur. The patient sees a provider, a service or procedure is performed, and a bill (claim) goes to the health insurance plan (payor/issuer) for reimbursement for those services that...
by Advize Admin | Mar 11, 2022 | Compliance
Risk adjustment is a newer payment methodology that is designed to allow for a proactive approach to managing healthcare. It does not seek to audit against current claims or encounters. It is a yearly collection of diagnosis codes to accurately build a total RAF (Risk...
by Brian Boyce | Mar 4, 2022 | Compliance
Background Anyone who has taken the CRC™ (Certified Risk Adjustment Coder) curriculum can tell you that risk adjustment was first utilized in the mid-90’s for Medicaid purposes. The goal of risk adjustment has always been to collect data on patients so that money...
by Erik Consorsha | Feb 4, 2022 | Compliance
Providers who are lucky enough to have their fraud, waste, and abuse matters resolved through a civil settlement (either via the US Attorney’s Office or the Office of Counsel to the Inspector General-a CMPL action), can sometimes have a clause in the settlement that...
by Erik Consorsha | Sep 10, 2021 | Compliance
The tagline from the CMS Website is “When Medicare Claims are submitted accurately, everyone benefits.” First – TPE why do we even care? Well, simple answer, it is a lovely little gift from CMS designed to help reduce claim denials and appeals through one-on-one...
by Erik Consorsha | Aug 13, 2021 | Compliance, FWA
The clock was about to strike midnight, and Scott Newman was desperately feeding pages into a scanner, trying to prevent thousands of dollars in prescription payments from turning into a pumpkin. As the owner of Newman Family Pharmacy, an independent drugstore in...
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