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Exceptional Coders | Innovative Technology

DaVita Subsidiary Settles Risk Adjustment Billing Case for $270 Million

Posted by David Fong on Nov 15, 2018 8:00:00 AM

Modern Healthcare reported recently that DaVita Medical Holdings will pay a $270 million settlement to the federal government over allegations that the company incorrectly inflated certain Medicare Advantage reimbursements above the fixed, risk-adjusted rate owed for care.

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Topics: Risk Adjustment, Medical Coding, Coding Compliance, Medical Coding Audits, HCC Coding

Overcoding and Overbilling: Two Problems with an Easy Solution

Posted by David Fong on Apr 3, 2018 8:00:00 AM

A recent article in Medical Economics pointed out a persistent problem that some physicians continue to overcode and overbill, despite increased focus on the cost of healthcare and scrutiny by federal regulators.  According to the article, a new report by ProPublica, which analyzed CMS data between 2012 to 2015, a number of physicians overcoded on services provided under Medicare’s Part B program.

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Topics: Medical Coding, Outsourcing, Coding Compliance, Medical Coding Audits

Stop Challenges Before They Happen with a Comprehensive Accuracy Review of Coding-Related Practices

Posted by David Fong on Jan 24, 2018 10:30:00 AM

A recent Becker’s Hospital Review article stated that Catholic Health had agreed to pay $6M to settle overbilling allegations. A nursing home subsidiary of the health system allegedly submitted claims to Medicare for the highest and most expensive levels of therapy when that type of therapy was not medically necessary or was unsupported by medical records. The allegations against Catholic Health were originally brought by a whistle-blower under the qui tam provision of the False Claims Act.

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Topics: HIM, Medical Coding Audits, Coding Compliance, Clinical Documentation

Revenue Cycle Management Expected to Grow 11% Annually

Posted by David Fong on Jan 11, 2018 7:00:00 AM

The medical sector has been undergoing a series of interminable changes over the last few years. In consequence, healthcare revenue cycle management (RCM) market is set to witness a marked growth because of the rising need for timely bill reimbursements and insurance claims. Increased complexity in the medical coding process has led to the necessity of RCM solutions that help reduce billing errors.

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Topics: Medical Coding, HIM, Medical Coding Audits, Denial Management, Coding Compliance, Clinical Documentation

DOJ Takes Action on Medicare Advantage Overpayments

Posted by David Fong on Sep 28, 2017 6:00:00 AM

As you are well aware, Congress created Medicare Advantage (MA) as a risk adjustment payment program that pays insurers more for sicker beneficiaries. Payers in MA receive a yearly fee for each enrolled member and monthly risk adjustment payments for each enrolled beneficiary, based partly on the person’s health status. This program can be open to fraud. Medicare Advantage payers received about $160 billion in 2015 for approximately 16 million beneficiaries. HHS estimates that the FY 2015 Medicare Part C gross improper payment estimate is 9.50 percent or $14.12 billion, along with the FY 2015 net improper payment estimate of 4.32 percent or $6.41 billion.


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Topics: Medical Coding, HCC Coding, Medical Coding Audits, Coding Compliance

Better Coding and Record Keeping Can Improve Care and Reimbursements for High-Risk Patients

Posted by David Fong on Aug 29, 2017 7:00:00 AM

An article in Modern Healthcare magazine reported that physicians who serve low-income patients with complex conditions are more vulnerable to financial losses in value-based payment models. The study that found these providers, many of them safety-net providers, didn't have the technological infrastructure to report the necessary data.


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Topics: Medical Coding, HCC Coding, Medical Coding Audits, Coding Compliance