Coding Compliance Risk

HCC Coding Compliance: Avoid Revenue Loss and Fines in Healthcare

By |2024-01-26T02:46:23+00:00January 12th, 2024|

Navigating the complex labyrinth of HCC coding is a daunting task for healthcare providers due to the frequent carrier changes to rules and regulations, and non-compliance could mean substantial revenue loss and hefty fines. In an era where healthcare services are under financial pressure like never before, unsurpassed accuracy in HCC coding has become an [...]

DOJ alleges Kaiser Permanente defrauded Medicare of $1 billion

By |2021-11-02T03:41:19+00:00November 2nd, 2021|

Kaiser Permanente and members of its healthcare consortium defrauded Medicare of nearly $1 billion by tacking on diagnoses to patients’ medical records to earn more in reimbursement payments, the Department of Justice claims in a complaint filed Monday. The DOJ alleges Kaiser looked through Medicare Advantage medical files and pushed physicians to retrospectively add new [...]

Offshore Coding: HIPAA Risks

By |2020-05-28T18:29:52+00:00May 21st, 2020|

From a compliance exposure perspective, we believe that the HIPAA risk associated with sending PHI abroad is simply untenable.  HIPAA is an American law that does not extend beyond our borders.  The only way to ensure HIPAA protection abroad is to do so contractually via a BAA.  There is no regulatory authority abroad for the [...]

Split Model Service Providers (Medical Coding Vendors with Offshore and Onshore Operations)

By |2020-05-28T18:31:39+00:00May 21st, 2020|

A troubling trend in the medical coding industry is a misleading split model where companies will have resources both onshore and abroad but not disclose which personnel are performing the services.  Some use their domestic resources almost exclusively for client facing interactions, such as sales and operations, but send all of the coding work to [...]

CMS Delays New Payment Model for Emergency Care Due To Covid-19

By |2020-04-15T05:05:43+00:00April 15th, 2020|

CMS has delayed the start date of its Emergency Triage, Treat and Transport model from May 1 until this fall. CMS selected 205 participants in February for the five-year ET3 model. CMS said it is delaying the start date because participants now are focused on responding to the COVID-19 pandemic. The new model aims to give ambulance care teams [...]

Texas Physician Guilty in $325M Fraud Case Involving False Diagnoses

By |2020-04-14T04:58:22+00:00February 1st, 2020|

A Texas physician was found guilty Jan. 15 for his role in a $325 million healthcare fraud scheme that involved falsely diagnosing patients with various degenerative diseases and then administering chemotherapy and other toxic drugs to patients based on the false diagnoses, according to the Department of Justice. After a 25-day trial, Jorge Zamora-Quezada, MD, was [...]

Healthcare billing fraud: Five Latest Settlements – Revenue Cycle E-Newsletter

By |2020-04-14T04:59:10+00:00February 1st, 2020|

Here are five healthcare organizations that entered into settlements to resolve billing fraud allegations in the past two months. You can . read the full story from Revenue Cycle E-Newsletter / Becker's Hospital Review here. 1. Wisconsin health system will pay $10M to settle whistleblower case 2. Physician group will refund Medicare $829K to resolve improper billing [...]

Concern Raised Over Estimated Billions Shown in Chart Reviews

By |2020-04-14T04:59:56+00:00December 13th, 2019|

The Office of the Inspector General of the United States undertook a recent study in which they reviewed a myriad of Medicare Advantage organizations (MAOs). There were concerns that these MAOs may be using chart reviews to increase the intake of their risk adjusted payments in an inappropriate manner. To those not in the know, [...]

Office Manager and Wife of Conway Arkansas Doctor Arrested for Medicaid Fraud

By |2020-04-14T05:00:42+00:00November 27th, 2019|

Leslie Rutledge, an Attorney General for the State of Arkansas, announced today that a Conway Optometrist's Officer Manager had been arrested and charged with for defrauding almost $600K from the Arkansas Medicaid Program during the course of a four-year period. Attorney General Rutledge went on record saying that “Medicaid funds are crucial to assist some [...]

Lenox Hill Hospital Pays $12.3 Million Settlement For Submitting Fraudulent Medicare Claims

By |2020-04-14T05:01:35+00:00November 25th, 2019|

The US Attorney for Manhattan, New York, and a Special Agent for the OIG's New York Regional Office, announced today that the US Federal Government has settled a civil fraud suit against Lenox Hill (a Manhattan Hospital) and its corporate parent Northwell. The Government’s complaint alleges that the two Defendants violated the False Claims Act [...]