Tip: Combatting fraud, waste and abuse

Each year, the OIG identifies healthcare programs that are vulnerable to fraud, waste, and abuse through erroneous claims. Using claim sampling techniques and audits, the OIG identifies billing vulnerabilities and concerns specific to SNFs. Results of these vulnerabilities are published as reports or listings of common errors and should be analyzed to determine whether they are concerns for your facility. At a minimum, your risk detection process should include the following:

  • Reviewing commonly identified errors listed on your MAC’s website
  • Ensuring that all technical requirements, eligibility verifications, and physicians’ orders are in place prior to billing
  • Implementing a process to determine whether your skilled documentation meets mandated level of care and medical necessity criteria
  • Verifying compliance with all billing rules and regulations
  • Ensuring that the MDS process includes accurate and timely completion
  • Identifying the appropriate primary diagnosis for skilled services and all pertinent comorbidities, conditions, and services
  • Employing a solid triple-check system to internally audit claims prior to submission

And as with any solid system, success depends heavily on continued monitoring of the process and meaningful collaboration within interdisciplinary team.


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Featured Event

Tuesday, October 6, 2020 - 07:00

2019 Revenue Integrity Symposium

The 2020 Revenue Integrity Symposium covers topics essential to revenue integrity, Medicare compliance, and the revenue cycle in acute care and long-term care settings.