tci Medicare Compliance & Reimbursement - 2007 Issue 26

CMS TRANSMITTALS: Make Sure Each NPI Matches Up To Only One UPIN -- Or You Could Be In For Headaches

Medicare could auto-deny 100 percent of suspicious claims.Watch out: Medicare's Program Safeguard Contractors (PSCs) will be on the lookout for "high-risk areas" soon. These are groups of claims with unusual patterns that show a potential for fraud and abuse. Warning signs could include: · a sudden change in billings, · a spike in billings, · the wrong specialty billing for some procedures, · the wrong diagnosis codes on claims, · beneficiary complaints, or· billing for bundled Part B services during a Part A institutional stay. Red flag: Another big warning sign would be a doctor ordering outside...

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