The Office of Inspector General (OIG) was formed in 1976 by President Gerald Ford through the Inspector General Act. Since then, the OIG has been key in fighting waste, abuse, and fraud in Medicare, Medicaid, and other Health and Human Services programs and is the
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Medicare determined that a practice had been billing X-rays globally for years, when it should have only billed X-rays with a modifier 26 for the professional interpretation of the service, as the practice didn’t own the X-ray equipment. The fallout of this oversight included an
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If you decide to participate in Merit-based Incentive Payment System (MIPS), you will earn a performance-based payment adjustment to your Medicare payment.
You earn the payment adjustment based on evidence-based and practice-specific quality data. You show you provided high quality, efficient care supported by technology by
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Whether you’re provider, medical coder, practice, practice manager, or auditor, you need to be knowledgeable of federal regulations that relate to fraud, abuse, and compliance.
Stay in the know: The five most important Federal fraud and abuse laws that apply to physicians are the False Claims
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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
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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
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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
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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
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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,
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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
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