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Home Health & Hospice Week

Fraud & Abuse:

MEDICARE COULD AUTO-DENY 100% OF SUSPICIOUS CLAIMS

Published on Tue Jun 05, 2007

Be sure to steer clear of these hot spots.

Watch out: Medicare's Program Safeguard Contractors (PSCs) will be on the lookout for "high-risk areas" soon and home care providers could be on the contractors' hit lists.

The high-risk areas are groups of claims with unusual patterns that show a potential for fraud and abuse. Warning signs could include:

• a sudden change in billings,
• a spike in billings,
• the wrong diagnosis codes on claims,
• beneficiary complaints,
• a high CERT rate,
• billing based on a deceased physician's orders, or
• billing for Part B services during a Part A institutional stay.

Red flag: Another big warning sign would be a doctor ordering outside services for a patient when the ordering doctor has never seen the patient. If your patient's doctor hasn't already billed for his own services provided to that patient, it could get you into claims trouble.

When they find a high-risk area, the PSCs can impose their own edits on your claims, including prepayment medical-review edits. They can also impose automatic denials on 100 percent of your claims, send Medicare Summary Notices (MSNs) more often, check your enrollment status, and work with beneficiaries more closely, according to Centers for Medicare & Medicaid Services Transmittal 210 (CR 5626).

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