Medicare Integrity Program Essay

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When the Federal Government covers items or services rendered to Medicare beneficiaries, the Federal fraud and abuse laws do apply. Medical bills may be denied and payments withheld by government and private payers when medical bills with coding errors are submitted for payment (Addressing Medical Coding and Billing, 2002). Along with the fact that Federal and State regulatory agencies may impose financial sanctions and disciplinary actions on the medical practice, medical providers may also be excluded from participation in any government-funded program under the False Claims Act. Id. Providers may be required to repay Medicare, Medicaid, and/or other payers for improperly coding claims and submitting erroneous medical bills. Id. In addition, …show more content…
The goal of the Medicare Integrity Program is to reduce payment error by identifying coverage and coding practices made by providers. Id. Payers can identify when medical providers make certain coding and billing mistakes, once a payer can identify the errors and determine that mistakes were intentionally made, the payer can then propose that an audit be performed on the medical provider. When Providers are not adequately prepared for an audit and when compliance is not high on their priority list, this can lead to financial sanctions and unnecessary disciplinary actions by State and Federal regulatory agencies. Id. In addition to audits, there are subsequent installments that providers need to be aware of at all times, such as reporting Medicare allowable cost data; developing internal controls; policies and procedures; conducting risk analysis; monitoring utilization review and quality of care; and developing an effective compliance program. Id. Failure on the part of the health care provider to comply with the State and Federal requirements of the medical audit or to implement stated corrective action plans might serve as cause for financial sanctions and disciplinary action. …show more content…
Id. Providers who ensure exact descriptions of the level of service performed can prevent level of service coding errors. Likewise, providers should not be careless when linking diagnosis and procedure codes, both need to be present in order to determine if the procedure is medically necessary. Making every effort to code to the highest level of specificity and it is recommended that staff check the alphabetical index of the ICD-9 book for patient’s conditions. Id. Additionally, providers should avoid using signs and symptoms to describe a medically necessary procedure or services provided when the diagnosis is not apparent and the chief medical complaint should always be documented. Id. Determining whether to code the office visit as a consult or a referral, can be perplexing for providers. When it is a consulting visit, the patient is normally required to revisit their primary care physician, and if medical care is provided to the patient, the visit is a referral and should be billed as a new patient. Id. The unbundling of multiple component services and billing, intentionally or not, is considered fraudulent or reckless to all payers. Finally, providers should periodically review diagnosis, service, and procedure codes documentation with office

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