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What Is Healthcare Fraud & Abuse?
Simply put, fraud is billing for services not rendered or misrepresenting services rendered. Abuse is billing for services that were rendered but were not reasonable and medically necessary for treatment of the patient’s illness or injury.
Examples of Healthcare fraud include:
Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain health care payments for which no entitlement would otherwise exist
Knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs
Making prohibited referrals for certain designated health services
Examples of Healthcare abuse include:
Billing for medically unnecessary and inappropriate services
Billing for an excessive number of services
Misusing codes on a claim, such as upcoding or unbundling codes
Healthcare abuse can adversely impact the health and safety of patients that receive medically inappropriate and/or excessive services and the providers of these services can also be exposed to criminal and civil liability.
The WCC Difference
A company rich in proven techniques for medical review, claims quality assurance and fraud detection, WCC has retained subject matter experts and processes to mirror CMS’ multifaceted approach to program integrity and benefit payment validations. WCC provides service support across the three major components of Program Integrity including Medical Review of claim submissions against associated patient medical records to assure services billed represent services actually rendered, Data Analysis of paid claims to detect aberrancies and anomalies in provider billing patterns that could represent fraud or abuse and Investigations of providers suspected of fraudulent or abusive practices based on Medical Review or Data Analysis results.
WCC currently provides Medicare/Medicaid claim medical and coding audits, Medicare/Medicaid claims data analysis and Medicare/Medicaid fraud investigations as well as related IT systems security and network engineering support to CMS Unified Program Integrity Contractors (UPICs) and CMS Zone Program Integrity Contractors (ZPICs). Medical Review services were also previously provided to CMS Medicare Administrative Contractors (MACs).
Our physicians, registered nurses, certified coders and other healthcare professionals are experienced in conducting healthcare claim and medical records reviews in support of healthcare payer program integrity and payment validation efforts. The reviews are conducted to assure that services billed accurately reflect services rendered in the medical records and that the services were medically necessary and appropriate, and paid in accordance with the payer’s coverage and reimbursement policies. Our staff specializes across all healthcare disciplines to perform medical records review and to support identification of potential fraud or abuse.
Our Medical Review team supports our clients in the areas of:
Prepayment and post-payment claim medical reviews including
Inpatient and Outpatient Services
Medical Equipment Suppliers
Coding Audits including
Upcoding, Miscoding and Unbundling Detection
Medical Necessity Reviews
Quality of Care reviews
Fraud Investigation Support
Identification and reporting of improper payments
These databases data are sampled and analyzed to identify anomalies in provider billing patterns that could represent potential fraudulent or abusive billing practices. Our statisticians and data analysts are versed in working with healthcare data in the SQL environment and have experience working with SAS and other Data Analysis software applications to develop and run algorithms that have been successful in identifying potential abusive billing practices and improper payments.
Our Data Analysis team also works with the client medical review staff to support both statistically valid and focused claim samples and for identifying overpayments based on medical review findings. Our Data Analysis also work with client investigative units to provide proactive fraud detection services and to respond to requests for data to support ongoing investigations including requests from federal and state law enforcement agencies.
WCC’s Investigators all have backgrounds in investigating potential healthcare fraud in support of our client’s established Program Integrity processes and priorities including:
Conducting background investigations
Provider and Patient interviews
Conducting Site Visits
Identifying the need for client administrative actions including sanctions and recovery of overpayments
Recommendation and preparation of cases for referral to Federal and state law enforcement for consideration and initiation of civil or criminal prosecution.
WCC provides a team of subject matter experts – from forensic computer analysts, licensed physicians, case managers, registered nurses, program integrity analyst, certified professional medical coders, experienced Medicare/Medicaid data analysts and scientists, statisticians, to quality assurance analysts and certified fraud investigators.
Workers Compensation Center, LLC
7010 Little River Turnpike, Suite 450 Annandale, VA 22003
Phone: (703) 663-7305 | Fax: (703) 941-8965