Duplicate/overlapping Bill audit Outpatient/inpatient overlap payments and unbundling. In 2010, ESRD issues HMS recovered more than Unbundling HCD errors $3 million for Downcoding Financial review/credit outpatient/inpatient overlap- Radiology billing errors balance and unbundling-related issues. Where policy is not Anesthesia billing Medicare coinsurance clear, we work with providers errors errors to help them understand the NCCI coding errors issue and the allowable and nonallowable exceptions to the rules. COB payment errors. HMS recovers more than $25 annually in excess million Outpatient Medicaid payments where Medicare and other third parties have made a primary payment. Inappropriate billing for professional and ancillary services. To date in 2011, we have identified more than $50 million in overpayments related to upcoding of physician services on behalf of clients. ESRD. HMS has recovered more than $25 million in ESRD-related overpayments for clients. Excess/duplicate days Overlapping services Cost of Care (COC). HMS included in per diem recovers more than $20 Patient-pay rate million annually through LTC underreporting financial audits. The majority Financial review/credit Bed hold days of recoveries are related to balance Date of COC issues. LTC Cost report auditing Crossover billing errors Duplicate day payments for LTC, hospital, and hospice LTC/hospice duplicate days. On behalf of one client, days we recovered more than $6 million duplicate payments for hospice/LTC in 2010. Unit billing errors Duplicate pharmacy/ In the past years, HMS physician therapy has audited claims that have Duplicate payment/ totaled more than $1 billion. early refill 340b overpayments Some audit findings have Return to stock Fraud patterns Pharmacy included duplicate claims, overpayments incorrect days’ supply or OTB COB issues quantity submitted based on physician's direction, and early refill.
Outpatient Duplicate/overlapping payments Unbundling Downcoding Radiology billing errors Anesthesia billing errors NCCI coding errors Bill audit ESRD issues HCD errors Financial review/credit balance Medicare coinsurance errors Outpatient/inpatient overlap and unbundling. In 2010, HMS recovered more than $3 million for outpatient/inpatient overlap- and unbundling-related issues. Where policy is not clear, we work with providers to help them understand the issue and the allowable and nonallowable exceptions to the rules. COB payment errors. HMS recovers more than $25 million annually in excess Medicaid payments where Medicare and other third parties have made a primary payment. Inappropriate billing for professional and ancillary services. To date in 2011, we have identified more than $50 million in overpayments related to upcoding of physician services on behalf of clients. ESRD. HMS has recovered more than $25 million in ESRD-related overpayments for clients. LTC Excess/duplicate days Patient-pay underreporting Bed hold days Date of Crossover billing errors LTC/hospice duplicate days Overlapping services included in per diem rate Financial review/credit balance Cost report auditing Cost of Care (COC). HMS recovers more than $20 million annually through LTC financial audits. The majority of recoveries are related to COC issues. Duplicate day payments for LTC, hospital, and hospice days. On behalf of one client, we recovered more than $6 million duplicate payments for hospice/LTC in 2010. Pharmacy Unit billing errors Duplicate payment/ early refill Return to stock overpayments OTB COB issues Duplicate pharmacy/ physician therapy 340b overpayments Fraud patterns In the past years, HMS has audited claims that have totaled more than $1 billion. Some audit findings have included duplicate claims, incorrect days’ supply or quantity submitted based on physician's direction, and early refill.
ScopeOfWork-RAC.docx