Healthcare costs are rising steadily, putting stress on our economy and our wallets. In 2011, $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. It is an undisputed reality that some of these health insurance claims are fraudulent or contained billing errors. In its Medicare Fee-for-Service 2011 Improper Payments Report, The Centers for Medicare and Medicaid Services (CMS) reported an overall fee-for-service error rate of 8.6 percent, representing $28.8 billion in improper payments. The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year. In 2010 the Government Accountability Office (GAO) released a report claiming to have identified $48 billion in what it termed as “improper payments.”
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While most providers and physicians are exercising great effort in an attempt to comply with complex laws and coding guidelines, the majority of health care fraud is committed by a very small minority of dishonest health care providers. Although they constitute only a small fraction, those fraudulent claims carry a very high price tag. Sadly, the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected members of our society - our physicians.
Private insurers are becoming more active in identifying billing errors, implementing their own efforts to recoup payments and pursuing other legal actions for overbillings. Some of these identified abuses include upcoding, unbundling, inappropriate modifier assignment, undocumented services, and lack of medical necessity. In recent years the government has become aggressive in identifying and prosecuting health care professionals and entities suspected of fraudulent and/or abusive billing practices.
Health care abuse is reckless disregard or conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in greater reimbursement. Health care fraud is an intentional misrepresentation, deception, or intentional act of deceit for the purpose of receiving greater reimbursement. This can include a billing and/or coding practice of:
· Invalid code assignments
· Unbundled services
· Inappropriate Modifier Assignment
· Undocumented services
· Medically unbelievable services
· Medically unnecessary services
At the heart of healthcare billing is a coding structure developed by the American Medical Association (AMA) called Physician's Current Procedural Terminology (CPT®,). Much of the efforts to identify overbilling, abuse or fraud begin with analysis of data involving CPT, as well as Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD-9 / ICD-10) codes. The manual process of auditing health care claims and dissecting medical documentation is complex and should only be performed by those who are familiar with the categories, elements and other complexities involved in coding applications.
PYRAMED, INC. is well positioned to serve the diverse needs of our various clients through:
· Coding Reviews - Review of bills for correct CPT®, HCPCS and ICD-9 nomenclature
· Coding Compliance - Assisting physician practices on correct coding conventions
· Healthcare Fraud Investigations - Auditing of medical files and the identification of patterns of aberrant coding practices
· Litigation and Testimony - For successful resolution of coding disputes