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busting myths about clinical claim review

Posted by Debi Behunin on 3/16/17 10:53 AM

We know that automated claim editing is unable to analyze many claims due to their clinical complexity, the most obvious examples being claims with modifiers 25 and 59. These simply pass through the system and get paid without any further intervention. That’s why clinical claim review—also known as clinical validation—is so valuable. Clinical validation is a process whereby a team of clinicians, nurses, and coding experts reviews potentially incorrect claims and makes a swift payment recommendation. Over the years we’ve heard questions and concerns from health plans about the value of clinical validation. Here are four common myths and our responses to set your mind at ease.

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the true costs of medical identity theft

Posted by Edie Hamilton, CPC on 1/11/17 11:07 AM

$13,500. That is the average cost victims pay to resolve medical identity theft—when they can resolve it.

Medical identity theft occurrences are becoming more common. Incidents increased 22 percent from 2014 to 2015, impacting more than 2.3 million people in the United States, per the Ponemon Institute’s Fifth Annual Study on Medical Identity Theft.

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tips to ensure your quality program actually improves quality

Posted by Verscend on 12/20/16 9:33 AM

The increasingly strong link between quality outcomes and payment in healthcare increases the importance of closing gaps in care, a critical component of the annual HEDIS® measurement and reporting process. Plans invest significant resources into HEDIS with the goal of obtaining high ratings, but how can your organization transform routine quality measurement and reporting activities into a true strategic advantage? Check out our latest infographic.

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best practices to ensure end-to-end payment accuracy in your organization

Posted by Verscend on 12/7/16 11:49 AM

As many healthcare organizations know, the frequently changing and extremely complex healthcare landscape has unintentionally created new opportunities to take advantage of the system. As a result, insurers need to work more aggressively than ever before to ensure complete payment accuracy. Our payment accuracy checklist, available in Verscend’s knowledge bank, offers insight to help your organization achieve end-to-end payment accuracy.

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are your improper payments hiding in plain sight?

Posted by Verscend on 10/5/16 10:17 AM

After years of focusing efforts on speeding up automated claim processing, most payers’ claim review systems have unintentionally let their guard down. As a result, improper outlier claims common to our industry continue to pass through automated systems right in plain view without getting flagged. For some payers, the impact can really sting, amounting to millions of dollars. Our latest infographic explores some of the most blatant examples of incorrect billing practices still going on today and what they may be costing you in inappropriate payments if not addressed.

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common FWA overpayments your automated claim editing system may miss

Posted by Verscend on 9/22/16 12:00 PM

The cost of healthcare continues to dominate headlines as the Affordable Care Act (ACA) expands managed care, and thus provides fraudsters with new opportunities to take advantage of the system. This new and complex healthcare landscape—along with its varied payment methodologies—has forced insurers to work more aggressively to contain their costs. One of the ways in which insurers can respond to this changing healthcare environment and address fraud, waste, and abuse (FWA) is by reducing billing errors.

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why "no assembly required" is a welcome phrase for fraud investigators and parents alike

Posted by Verscend on 7/27/16 10:29 AM

If you’ve ever purchased a bunk bed, swing set, or bicycle for your child, you likely recall the hours it took to progress from a neatly packaged box of parts to a finished product. The concept of “no assembly required” got us thinking a bit more about real-life, classic product assembly struggles and how they relate to everyday healthcare fraud, waste, and abuse (FWA) situations in which turnkey allegations could be helpful to special investigations units. 

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busted 2016: prominent healthcare fraud schemes

Posted by Verscend on 6/29/16 10:31 AM

The National Health Care Anti-Fraud Association (NHCAA) estimates that tens of billions of dollars are lost each year to fraudulent healthcare practices. Whether it’s intentionally defrauding a health plan or wasteful billing practices due to inattention, fraud, waste, and abuse (FWA) has grown too large to ignore. The U.S. Department of Justice, Federal Bureau of Investigation, and Centers for Medicare & Medicaid Services (CMS) often work in conjunction to pursue the largest fraud cases, resulting in the exposure of multimillion dollar schemes.

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how to fine tune your investigation approach

Posted by Verscend on 6/15/16 11:43 AM

For health plans’ special investigative units (SIUs), the notion of wading through a pile of false leads before finding actionable information may often feel like a waste of time. However, determining which case referrals to pursue doesn’t have to be a complicated and confusing process.

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fast-tracking FWA investigations with turnkey allegations

Posted by Shuying Shen, Tim McBride, and Ryan Cleverly on 4/28/16 8:11 AM

Healthcare fraud, waste, and abuse (FWA) investigators have a tough job. Keeping pace with the latest schemes, continuously weeding through hundreds of false-positive leads, and understanding the right time to pursue a case are just a few of the challenges a health plan’s special investigative unit (SIU) faces. When armed with the right pieces of information to immediately open a solid case, SIUs can quickly take intelligent action to educate providers, recover funds—or even prevent payment before it’s made.

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