Fraud and Abuse
MediConnect Global understands how important it is for health plans to do periodic audits to identify any type of fraudulent billing practices.
According to the National Health Care Anti-Fraud Association, estimates are that 3% to 10% of health care spending is lost to health care fraud. This means that the price tag associated with health care fraud can range anywhere from $68 billion to $226 billion each year.
MediConnect’s Fraud and Abuse group consists of an experienced team of coders who audit retrieved medical records to ensure that the codes on submitted claims follow plan guidelines. Coders check for instances of up-coding, charging for services never rendered, or manipulation of information within the medical record or claim which results in incorrect reimbursement.
Effective auditing requires an understanding of coding principles. To satisfy health plan requirements, the codes billed to a health plan must be supported in the medical chart. When performing a chart audit MediConnect coders do the following:
Review all CPT/HCPCS Codes Submitted
Coders determine if the documentation in the chart supports these codes.
- Review all Modifiers
Coders determine if the documentation supports the use of specified modifiers.
- Review all ICD-9 CM Codes
Coders determine if the documentation supports these codes.
- Review the Dates of Service Billed
Coders validate that these dates of service are included in the medical record and were performed.
Review Documentation
Coders insure that all notes are legible, dated, and signed.
- Provider Education
As an invaluable resource to both health plans and the providers included in any coding audit, provider education materials are a tool to help providers identify areas for improvement in their record documentation and also provide general coding guidelines. MediConnect has standard provider education materials but can also develop additional customized materials.
