by Advize Admin | Oct 20, 2023 | FWA, SIU
As someone who has retired twice already but is still working, I may not be the best person to answer this question but I am aiming this query more at the fraud hunt than the job hunt. A hunter or fisherman answers this question all the time. Do we quit when it gets...
by Advize Admin | Jul 14, 2023 | FWA
Self doubt is a necessary part of the process when making claim determinations. As a reviewer, you have the ultimate decision-making authority as to whether a re-opened claim should be denied and the money recouped. You should be asking yourself whether the...
by Advize Admin | Jul 7, 2023 | FWA, Medical Record Auditing
Newly approved procedure codes, devices and DME are like the watering holes on the Serengeti. They are gathering spots for fraudsters and great hunting grounds for those looking to identify and stop the FWA. As a fraud hunter, you must follow the data trends to...
by Advize Admin | Jan 20, 2023 | OIG Files
We work very closely in the payor and provider space to ensure that fraud, waste, abuse (FWA) and compliance are at the forefront of the payment integrity continuum. This is particularly the case when working to conduct medical record reviews and identify over...
by Advize Admin | Dec 2, 2022 | Compliance, FWA, Medical Record Auditing, OIG Files
When you first open this article, the most glaring of things is the time frame from which the audit was derived. 2011-2013 data is at this point so aged, the calculation of $1,000 per patient enrolled in a Medicare Advantage (MA) as the overcharged amount is simply...
by Advize Admin | Dec 2, 2022 | Coding, FWA, Medical Record Auditing
Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average. Summaries of the 90 audits, which...
by Advize Admin | Oct 14, 2022 | Healthcare
It is the annual fall season of Medicare sales pitches and we have seen a rise in Celebrity Medicare Sales pitches. We are happy to see CMS creating tighter rules around the sales pitches and confusion. We have seen seniors fall victim to different Medicare...
by Advize Admin | Sep 30, 2022 | Compliance, FWA
Massachusetts has become the latest state to settle with health insurance giant Centene Corp. over allegations that it overbilled the state’s Medicaid program for pharmacy services, KHN has learned. Centene, the nation’s largest Medicaid managed-care insurer, will pay...
by Advize Admin | Jan 21, 2022 | Healthcare
Some health insurance brokers in the market are enrolling people into ACA (Affordable Care Act) health care plans without their consent, perhaps for the commissions, a move that could put consumers in danger of owing back the subsidies connected with the coverage. The...
by Advize Admin | Jan 14, 2022 | Healthcare
A new rule took effect recently that requires commercial payors to provide reimbursement for in-home COVID-19 testing, at a rate of eight (8) test kits per person, per month. Although well intended, the process for seeking reimbursement from commercial payors...
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