The Office of Inspector General (OIG) plays an important role in negotiating, developing, and enforcing corporate integrity agreements (CIAs). As a condition of settlement in a variety of civil and false claim cases, OIG will require an organization to incorporate a CIA in exchange for   Read more..

What is a compliance plan? A compliance plan is a collection of steps that a provider, organization, or practice establishes to ensure adherence to federal and state regulations. OIG developed voluntary compliance program guidance in an effort to help organizations with their compliance programs. Resources   Read more..

Medicine codes for both therapeutic and diagnostic services include injections, physical medicine, and rehabilitation services. These are some of the most difficult services to audit and, as a result, some of the most frequently audited in the medicine section of CPT®. Injections and infusions Injections and   Read more..

Doctors deal with interruptions every day. They need to call a patient back. The coding department asks them for clarification on a patient charge. Clinicians and staff come in to talk to them. Although the intention is there, the physician may not document the information   Read more..

National healthcare fraud is on the upswing, with a 400% increase in annual takedowns since 2013—and this, despite sequestration of mandatory funding for the Department of Justice (DOJ), the Department of Health & Human Services (HHS), the Office of Inspector General (OIG), and the FBI. Take   Read more..

Coding is integral to claim submission. To prepare and submit a claim for reimbursement, you need documentation of all services and procedures performed and the reason, providing a diagnosis for each to demonstrate medical necessity. Medical practices use a superbill, also called an encounter form,   Read more..

Recoup lost revenue by following up on denials.   After a claim has been properly documented, coded, and submitted for payment, a few things could happen. Hopefully, the insurer pays the claim and the office receives the appropriate reimbursement. But there are other scenarios that could   Read more..

In 2003, Medicare established their Fee for Service (FFS) Recovery Audit Program as part of the Medicare Prescription Drug, Improvement, and Modernization Act. Recovery Auditors held a three-year-long demonstration project across six states, between 2005 and 2008, to determine the potential for identifying improper reimbursement   Read more..

After an extensive outreach with clinicians, patients, and other stakeholders, CMS tweaked their original strategic objectives to drive progress and improvements. These minor enhancements to the strategic objectives will help guide their final policies and future rule-making in order to design, implement, and advance a Quality   Read more..

In the 2018 Medicare Fee Schedule rule, CMS reviews MACRA patient relationship categories and codes, their development and timelines, and provides details for the initial claims-based reporting of the relationship categories and codes to CMS. These patient relationship categories and codes define and distinguish the   Read more..