Combatting fraud, waste, and abuse through erroneous claims

Jun 07, 2019
The Bottom Line

Each year, the OIG identifies healthcare programs that are vulnerable to fraud, waste, and abuse through
erroneous claims. Using claim sampling techniques and audits, the OIG identifies billing vulnerabilities and
concerns specific to SNFs. Results of these vulnerabilities are published as reports or listings of common errors
and should be analyzed to determine whether they are concerns for your facility. At a minimum, your
risk detection process should include the following:
• Reviewing commonly identified errors listed on your MAC’s website
• Ensuring that all technical requirements, eligibility verifications, and physicians’ orders are in place
prior to billing
• Implementing a process to determine whether your skilled documentation meets mandated level of
care and medical necessity criteria
• Verifying compliance with all billing rules and regulations
• Ensuring that the MDS process includes accurate and timely completion
• Identifying the appropriate primary diagnosis for skilled services and all pertinent comorbidities,
conditions, and services
• Employing a solid triple-check system to internally audit claims prior to submission

And as with any solid system, success depends heavily on continued monitoring of the process and meaningful
collaboration within the IDT.

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