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Shield your providers from lost revenue and noncompliance through internal auditing. If you treat billing, coding, and compliance audits like routine annual physicals or yearly flu shots, you’re shortchanging your practice or facility. While regular checkups are important to your health and that of your business, audits go beyond general maintenance. They could uncover coding […]
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According to the United States DOJ, Traverse Anesthesia Associates, along with several anesthesiologists are paying over $ 600K to resolve allegations that they consciously incorrectly submitted certain anesthesia claims to Medicare. Investigators mentioned that TAA and six of their anesthesiologists didn’t meet the regulative needs and conditions of payment for billing those services as medically directed.
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First Assistant U.S. Lawyer Jennifer Arbittier Williams proclaimed that Richard P. Frey, D.O., and Physicians Alliance Ltd. (“PAL”) have agreed to pay nearly $ 180,000 to resolve liability underneath the False Claims Act for the alleged improper charge of “P-Stim” devices. From may 2013 through June 2014, Frey and PAL billed Medicare for the implantation of neurostimulator electrodes, a surgical operation generally necessitating an OR for which Medicare reimburses thousands of dollars. Frey didn’t conduct surgery, however. Instead, he applied a “P-Stim” device in a workplace setting while not using surgery methods or general anaesthesia.
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The post Doctor’s Practice to Pay Nearly $ 180K to Resolve False Claims Act Liability Regarding “P-Stim” Devices appeared first on The Coding Network.
Beaver Medical Group L.P. (BMG) and a doctor who works for it, Dr. Sherif Khalil, have agreed to pay a little over the amount of $ 5 million to resolve accusations that they falsely reported diagnosis codes to plans of Medicare Advantage, thereby causing said plans to receive inflated payments. BMG is headquartered in Redlands, CA. “The United States relies on healthcare providers to submit accurate diagnosis data to Medicare Advantage plans to ensure those plans receive the appropriate compensation,” said Jody Hunt, Assistant Attorney General of the DOJ’s Civil Division. “We will pursue those who undermine the integrity of the Medicare program and the data it relies upon.”
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The list of clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS as following,
HCPCS Advanced Imaging Procedure Codes,
70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76498, 77046, 77047, 77058, 77059,
70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, 76497
76390
78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78205, 78206, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78270, 78271, 78272, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78320, 78350, 78351, 78399, 78414, 78428, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78630, 78635, 78645, 78647, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78710, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78805, 78806, 78807, 78811, 78812, 78813, 78814, 78815, 78816, 78999
C8900, C8901, C8902, C8903, C8905, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936
MA Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition
MB Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
MC Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
MD Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances
ME The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MF The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
MG The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MH Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18)
G1000 Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program
G1001 Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program
G1002 Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program
G1003 Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program
G1004 Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program
G1005 Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program
G1006 Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program
G1007 Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program
G1008 Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program
G1009 Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program
G1010 Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program
G1011 Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program
Reference: New Modifiers and G Codes Effective January 1, 2020
January 1, 2020, marks the start of the Appropriate Use Criteria (AUC) program educational and operations testing period, at which time Medicare Administrative Contractors (MACs) will begin accepting AUC-related modifiers on claims for advanced diagnostic imaging services furnished to Medicare Part B patients. The voluntary participation period ends December 31, 2019. Know AUC Program Requirements […]
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Joseph P. Galichia MD, the previous owner of the Wichita-based Galichia Medical, after quite some time, reached Fraud Claim Act settlements with the Feds in 2000 and 2009 amounting to nearly 6 Million Dollars. This was his third time settling with the US Federal Government for such behavior.
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The post Kansas Doctor Forks Over Almost 6 Million in Settling 3rd False Claims Case in Twenty Years appeared first on The Coding Network.
Jaime L. Sepulveda, MD, LLC (d/b/a Miami Urogynecology Center), Jaime L. Sepulveda, M.D., and Sujata Yavagal, M.D. (collectively, “Miami Urogynecology Center”), South Miami, Florida, entered into a $ 173,768.08 settlement agreement with OIG. The settlement agreement resolves allegations that Miami Urogynecology Center submitted claims to Medicare for items or services that it knew or should have known were not provided as claimed and were false or fraudulent. Specifically, OIG contended that Miami Urogynecology Center submitted claims for: (1) diagnostic electromyography services using CPT code 51784 when therapeutic, not diagnostic, services had been provided; (2) pelvic floor physical therapy services using CPT codes 97032 and 97110 when those services were provided by an unqualified individual; and (3) evaluation and management (E&M) services using CPT codes 99213 and 99214 that were billed in conjunction with pelvic floor therapy procedures when no separate and identifiable E&M services were provided. OIG’s Consolidated Data Analysis Center and Office of Counsel to the Inspector General, represented by Senior Counsels Srishti Sheffner and Michael Torrisi, with the assistance of Program Analyst Mariel Filtz, collaborated to achieve this settlement.
The post Florida Physicians and Practice Settle False and Fraudulent Claims Case appeared first on The Coding Network.
On November 19, 2018, Southern Connecticut Vascular Center, LLC (SCVC), Stratford, Connecticut, entered into a $ 792,076.76 settlement agreement with OIG. The settlement agreement resolves allegations that SCVC submitted claims for Healthcare Common Procedure Coding System (HCPCS) code 96965 when those claims were for a procedure that was already included as a component of the duplex ultrasound procedures for which SCVS submitted claims using HCPCS codes 93970 or 93971 for the same beneficiary on the same dates of service. The OIG further contends that the submission of claims for HCPCS code 93965 were for a procedure that should not have been separately billed and was not medically necessary. Senior Counsels Geoffrey Hymans and Joan Matlack, with the assistance of Program Analyst Mariel Filtz, represented OIG.
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