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Hospice Audit and Investigative Actions are Expected to Rise in 2024

(November 20, 2023): Medicare, Medicaid, and most private insurance plans cover hospice care and related services. To be eligible for hospice care,1 a patient must be certified as terminally ill and have a life expectancy of six months or less.  In recent years, the hospice industry has exponentially grown, and the number of Federal, State …

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Balloon Sinuplasty Fraud / Balloon Dilation Fraud Prosecutions are Increasing Around the Country

(May 25, 2022): In recent years, federal regulators have initiated a significant number of audits and investigations examining the improper billing of claims for balloon sinuplasty / balloon dilation procedures by Otolaryngologists (commonly referred to as Ear, Nose and Throat (ENT) physicians. Depending on the specific facts in each case, the improper billing of balloon …

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Prepayment Reviews and Audits of Medicare Claims are Ongoing. Are Your Claims Being Audited?

(January 19, 2021):  As you will recall, on March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) suspended most Medicare audits and reviews due to the COVID-19 national emergency.  In early August, CMS instructed its contractors to resume their prepayment and postpayment audit activities. Over the last six months, we have seen a …

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Audits of Respiratory (CPT Code 87633) / Gastro (CPT Code 87507) Panels are Ongoing.

(January 3, 2021):  In recent months, we have seen a significant rise in the number of Medicare and Medicaid audits focusing on the medical necessity of certain outpatient Respiratory Viral Panels (CPT Code 87633) and Gastrointestinal Pathogen Panels (CPT Code 87507).  Unfortunately, many of these audits seem to be merely the latest example where payors …

Audits of Respiratory (CPT Code 87633) / Gastro (CPT Code 87507) Panels are Ongoing. Read More »