Healthcare Fraud, Waste, and Abuse: Are You Looking at the Right Claims?
Healthcare Fraud, Waste, and Abuse: Are You Looking at the Right Claims?
Healthcare fraud, waste, and abuse continues to be a major focus for CMS and other federal agencies.
During a recent Leadership Lab podcast, Asbel Montes sat down with former CMS Chief Operating Officer Kim Brandt to discuss the agency's evolving approach to compliance, including the increased use of advanced analytics and proactive identification of high-risk billing patterns.
I would strongly encourage anyone in the healthcare revenue cycle space to listen to this podcast and consider whether their organization is prepared.
One of the key takeaways from the discussion is that providers should not wait for an external audit to identify potential vulnerabilities. Instead, organizations should proactively evaluate the areas of their business that present the greatest compliance risk.
For every provider, those high-risk claims may look different:
Home Health agencies may review documentation supporting homebound status, skilled need, visit utilization, or episode trends.
DME suppliers may evaluate high-risk product categories, medical necessity documentation, recurring supply orders, or billing during overlapping care settings.
EMS providers may review repetitive non-emergency transports, ALS assessment utilization, or patients utilizing both ambulance and chair car transportation.
NEMT providers may evaluate prior authorizations, recurring trips, trip frequency by patient, or billing patterns by payer.
The objective is not to review every claim. It is to identify the claims and patient populations that deserve a closer look based on risk.
Organizations that routinely analyze higher-risk populations are better positioned to identify documentation gaps, billing inconsistencies, workflow opportunities, and potential compliance concerns before they become external audit findings.
If you are unsure where to begin or would like assistance identifying meaningful claim populations for review, our team is always available as a resource.
By Corey Chapman Vice President of Client Services, Solutions Group Services