Monthly Archives: September 2015

GE contracts with four centers of excellence

Did you know that GE, one of the nation’s largest employers, has contracted with four hospitals in different parts of the country to provide hip and knee replacement surgeries to employees? These “centers-of-excellence” are created with medical providers rated highly for quality and experience in a given specialty. The agreements typically involve a bundled payment, Read More

National Provider Identifier

Did you know that every medical provider in the country is assigned a unique identifier like a social security number, referred to as an NPI number (National Provider Identifier)? This is used to track that provider’s activity, and is used for government reporting to track questionable payment patterns.Read More

Recovery auditing in Medicare for fiscal year 2013

Did you know that the Center for Medicare & Medicaid Services (CMS) enlists the help of outside Recovery Audit Contractors (RAC’s) to identify and correct improper payments that have occurred? For FY2013, this resulted in the correction of over 1.5 million underpayments and overpayments, and returned in excess of $3.0 billion to the Medicare Trust Read More

Comprehensive Error Rate Testing

Did you know that Medicare’s improper payment rate is calculated annually via the Comprehensive Error Rate Testing (CERT) program? Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. For the twelve months ending June 30, 2013, the overall error Read More

The $272 billion swindle

Did you know that certain areas of the country are a “hotbed” of fraudulent medical billing, including such places as Miami, New York City, Detroit, Houston, Los Angeles, Tampa, and Baton Rouge? Organized crime in these regions systematically target & exploit control weaknesses in healthcare reimbursement systems, particularly Medicare.Read More

Doctors make millions off of Medicare

Did you know that the Center for Medicare & Medicaid Services (CMS) released data in April showing the summary of payments made by Medicare to 880,000 physicians nationwide? This data has been used to identify providers with patterns of suspect or even potentially fraudulent billing. One ophthalmologist from West Palm Beach, FL collected nearly $21 Read More

Medicare overpaid docs billions for office visits, OIG says

Did you know that according to the Health & Human Services Office of Inspector General, Medicare overpaid physicians $6.7 billion for evaluation and management services in 2010? The overpayments were caused primarily by incorrect medical coding and inadequate documentation. This represented more than one-fifth of overall payments issued for E/M services that year.Read More

APNewsBreak: Medicare bought meds for dead people

Did you know that Medicare’s operating rules allow it to pay for prescription drugs up to 32 days after a patient’s death – not a best practice? About 80% of these prescriptions were filled at neighborhood pharmacies, reflecting criminals acquiring the drugs to presumably sell on the black market at a hefty profit. High-priced drugs Read More

Big Pharma’s Favorite Prescription: Higher Prices

Did you know that certain prescription drugs have increased in cost at rates up to nearly 850% since 2007 versus an increase in the Consumer Price Index (CPI) of 12% during that period? Examples include Avonex (+147%), Gleevec (+158%), Viagra (+159%), EpiPen (+222%), Humulin R U-500 (+354%) and Xyrem (+841%). There are 15 cancer drugs Read More