Medicare Fraud And Compliance

Coding, Billing and Reimbursement

Consultation and Auditing

Provided By

Abbey & Abbey, Consultants, Inc.

  • Introduction, Notes & Caveats
    • Abbey & Abbey, Consultants, Inc., has for a number of years provided specialized consultation for health care providers (physicians, clinics, hospitals, hospital systems) in the area of revenue enhancement and compliance reviews. Litigation support services have also been provided to legal counsel for health care providers.
    • Recently, a significant surge has occurred in the monitoring and auditing activities on the part of the OIG, DOJ, FBI and related state agencies in the area of coding, billing and reimbursement. Recent passage of the Kennedy-Kassebaum Bill (The Insurance Portability and Accountability Act) has created significantly increased funding for various federal agencies to conduct investigations in this area. Hospitals, physicians and clinics should ALL anticipate that there will some form of contact and auditing in the next several years.
    • Note: Since this is an area in which both civil litigation and/or criminal prosecution can occur, the consultants at Abbey & Abbey, Consultants, Inc., strongly suggest that our clients retain our services in this area through their legal counsel. Abbey & Abbey, Consultants, Inc., is not a law firm and does not provide legal counsel or give legal opinions.
    • See two now out of date example programs

Areas Of Review/Auditing

  • Outpatient Documentation
    • Quality, Legibility, Completeness, Accuracy
      Documentation Standards
    • Ordering/Attending Physician
    • Documentation System
    • Location Of Documentation Development
    • Specialized Areas (Laboratory, Radiology)
  • Interface Of Payment Systems
    • Outpatient To DRGs
    • Outpatient To Physician - RBRVS
    • Outpatient To Subacute
    • Outpatient To Skilled Nursing
    • Outpatient To Home Health
  • Medical Necessity Standards
    • General Provision Of Services
    • Emergency Department Services
    • Observation Admit/Discharge
    • Hospital Admit/Discharge
    • Special Area Medical Necessity
  • Outpatient Coding
    • Accuracy And Completeness
    • Qualifications Of Personnel
    • Utilization Of Automated Systems
    • Sequencing Of Codes
    • Correlation Of Codes - HCFA-1500 - UB-92
    • Coding Policies And Procedures
    • HCFA's [now CMS's] Correct Coding Initiative
  • Physician Related
    • Face-To-Face Services
    • Medical Staff Bylaws And Policies
    • Incident-To Services
    • Specialty Clinics - Place Of Service
  • Outpatient Organization
    • Outpatient Department Requirements
    • Rural Health Clinics
  • Non-Physician Providers
    • PA, NP and CNS Independent Billing
    • Other Non-Physician Billing
  • Billing And Claims Process
    • Integrity Of Codes
    • Charge Master Code Overrides
    • Quality Of UB-92s Generated
    • Systematic Edit/Review Of Claims/Detailed Bills
    • Inclusion And Appropriateness Of Modifiers
  • Charge Master Related
    • Non-Covered Services
    • Static Coding Versus Dynamic Coding
    • Supply Charges
    • Equipment Charges
    • Personnel Time Charges
    • Correlation Of CPT/HCPCS To RCCs
    • Charge Explosion Reporting
    • Laboratory Bundling/Unbundling
    • Appropriateness Of Charge Descriptions
    • Consistency And Reasonableness Of Charges
    • Self-Administrable Drugs
    • Special Drugs/Supplies Reporting
  • Cost Report Related
    • Charge Master Categorization
    • Proper Development Of Cost Reports

Establishing A Compliance Program

The process of reviewing the coding-billing-reimbursement process and system for possible compliance violations should be viewed as part of a larger, overall process undertaken by the health care provider. Additional information is available for the development of such a program. A compliance program addresses other, additional compliance concerns - OSHA, ADA, FLSA, and so forth.

Send us an e-mail to request further information (