Center for Medicare Services reports to Congress, action taken against 938 providers due to utilization of new Medicare anti-fraud software system

Actions included revocation of billing privileges, implementation of prepayment reviews, referral to law enforcement and suspension of payments.

August 1, 2014 — The Center for Medicare Services said they discovered/prevented more than $210 million of improper Medicare “fee for service” payments with their new “state-of-the-art” fraud prevention system. This equates to double that of last year and proves to them the efficacy of increasing utilization in the future.

One highly publicized case, known to many chiropractors, was a group practice identified as a “high-risk for inappropriate billing.” They were surprised by an unannounced site visit that showed the aides were not qualified to deliver services.

They removed the doctor from the Medicare program and prevented $700,000 of Medicare payment from being honored.

Most actions against chiropractors are relative to the physician not releasing the patient from active care when active care can no longer be justified via appropriate documentation. Remember, patients are to be issued an ABN form and released from active care when such can no longer be documented to Medicare’s standard.

This standard has nothing to do with a chiropractic definition of “maintenance care.”

All practitioners are required to understand the proper use of an ABN form and audit such, with an appropriate audit tool, annually at a minimum. Action steps should be taken to remedy deficiencies.

Source: HIPAA Compliance Services