| Over the course of the past two decades,
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| | program,
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| federal and state enforcement agencies
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| | 2. Competent management of medical
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| have investigated medical billing
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| | notes, and
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| incidents and brought multiple
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| | 3. Continuous monitoring of potential
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| enforcement actions against healthcare
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| | audit triggers.First, the existence of a
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| practices. The list of agencies tasked
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| | compliance program may determine whether
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| with billing compliance enforcement
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| | the payer can routinely handle the matter
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| includes federal Department of Justice,
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| | as an innocent overpayment mistake or it
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| the Office of Inspector General (OIG) at
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| | must be investigated by the OIG as a
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| the Department of Health and Human
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| | potentially fraudulent act.Next, careful
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| Service, state Medicaid fraud control
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| | management of medical notes is a basis
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| units, and others.The number of medical
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| | for a successful audit defense, which
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| billing fraud investigations and
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| | often reduces the damages significantly
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| enforcement actions has been steadily
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| | and helps avoiding a repeat audit a few
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| growing. For instance, according to
| |
| | years later.Finally, audit trigger
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| BillingWiki, thirteen articles and news
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| | monitoring ensures compliance of both
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| items were published on the topic of
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| | cumulative service patterns across
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| medical billing fraud during May of 2006.
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| | multiple patients and individual
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| In addition to growing frequency of
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| | treatments. Real-time juxtaposition of
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| incidents, the severity of penalties has
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| | histograms of CPT code frequencies
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| also escalated from relatively
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| | between practice and national averages
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| non-adversarial audits and occasional
| |
| | compares service patterns and alerts of
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| return of payments to fines, suspension
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| | potential compliance
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| or loss of license, and imprisonment.Six
| |
| | infringements.Individual treatment
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| out of thirteen news items and articles
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| | compliance is ensured when no specific
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| about medical billing fraud published in
| |
| | CPT code exceeds its monthly limits, such
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| May 2006 involve chiropractors
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| | as billing a 9894X on each visit, or
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| (BillingWiki/Compliance). The remaining
| |
| | billing a 97140 manual therapy in place
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| items are distributed more or less evenly
| |
| | of a manipulation code because it pays
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| across such specialties as psychiatry,
| |
| | more, or charging for 97149 together with
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| gynecology, neurology, orthopedics, and
| |
| | 9894X, while both procedures linked to
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| aged care. The growing frequency of
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| | the same diagnosis. In the latter
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| audits and increasing severity of
| |
| | example, performing both an adjustment
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| penalties are symptomatic of inadequate
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| | and a soft tissue manipulation in the
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| attention to billing compliance at the
| |
| | same part of the body for the same
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| chiropractic office.An insurance company
| |
| | complaint is illegal and a repeat
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| typically performs post-payment audit by
| |
| | submission of such a claim may trigger an
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| soliciting medical notes for a random
| |
| | audit.An environment of high volume of
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| sample of paid claims during the previous
| |
| | patient encounters creates thousands of
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| year. Next, the proportion of inadequate
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| | possibilities to deviate from normal
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| medical notes defines the overpayment
| |
| | distribution of services and trigger an
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| percentage. The total amount of
| |
| | audit. Therefore, real time analysis
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| overpayment is then calculated by
| |
| | requires powerful technology
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| applying the overpayment percentage to
| |
| | infrastructure and competent legal
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| all payments over the past six
| |
| | coverage. Such infrastructure must
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| years.Billing compliance is doctor's
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| | handle all compliance aspects together,
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| responsibility and ignoring it often
| |
| | which necessitates modern Vericle-type
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| results in practice ruin. To avoid
| |
| | integrative approach, combining billing,
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| billing audit risks, some doctors have
| |
| | monitoring, and medical record management
|
| elected to work on cash-only basis,
| |
| | components in a single and comprehensive
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| collecting cash payments directly from
| |
| | system.Yuval Lirov, PhD, author of
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| the patients instead of submitting
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| | "Mission Critical Systems Management"
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| medical claims to insurance agencies.
| |
| | (Prentice Hall, 1997), inventor of
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| However, such tactics does not help avoid
| |
| | multiple patents in artificial
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| the potential audit because patients
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| | intelligence and computer security, and
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| submit requests to pay the claim to the
| |
| | CEO of (medical billing technologies).
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| healthcare insurance company on their
| |
| | Vericle delivers comprehensive practice
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| own.Since the top two reasons for
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| | workflow engine that integrates patient
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| post-payment audits are over utilization
| |
| | scheduling, electronic medical records
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| of certain CPT codes and hot line calls
| |
| | (EMR), billing, transcription, and
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| by patients and staff, the best strategy
| |
| | compliance management. It improves
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| to manage post-payment audit risk has
| |
| | billing performance and reduces audit
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| three prongs:1. Formal compliance
| |
| | risk.
|
