David Bernardi

Medicare fraud is a major issue, costing Americans billions annually. CBS News Texas I-Team exposed a Grand Prairie company linked to over $200 million in fraudulent billings, leading many viewers to share their experiences as victims. Dwight Sandell and Debbie Gollihugh faced fraudulent charges on their Medicare accounts for items they never ordered, like urinary catheters. Similarly, Paula and Winfield Bridge were billed for unordered COVID test kits by multiple Texas companies. Companies like Lone Star Medlab and Peak Health Diagnostics vanished after investigations. The Centers for Medicare & Medicaid Services (CMS) identified 11 companies responsible for nearly $3 billion in fraudulent catheter billing, successfully blocking most funds. Medicare temporarily halted payments for COVID test kits due to fraudulent claims and has implemented safeguards to prevent further fraud. Despite a recent $2.7 billion healthcare fraud crackdown by the U.S. Department of Justice, the Texas companies were not charged. Medicare fraud victims are urged to report issues at 1-800-MEDICARE. Our billing team ensures proper billing practices by meticulously verifying documentation to support clinical services or devices. We conduct thorough audits to confirm accuracy, prevent fraudulent claims, and adhere to compliance standards. This diligence protects patients from incorrect charges and upholds financial integrity, ensuring trust between healthcare providers and patients. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Microsoft KTVT | CBS DFW

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Something to consider for #vbc: The average Medicare beneficiary sees two specialists, and 30% of beneficiaries see five or more(!). Managing VBC contracts with multiple providers and overlapping episodes can be complex (think a pregnant woman with diabetes, a diabetic/CHF patient undergoing hip replacement). Some helpful ideas in the blog here (e.g. the importance of provider transparency), but of course, it's all about the specifics of your situation.

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Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

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How does a $497k chart audit risk turn into a recommended $6.8M recoupment? Impact extrapolation, that is how. The rule now allowing the OIG to recommend larger recoupments are now in effect. This is the first of two audits published today. It isn't too often that the OIG publishes not one, but two, findings reports in a day. Let's dig into the first one. The article linked below is tied to a 2017 and 2018 date of service audit of high risk diagnosis codes by the OIG. Beginning with 2018 dates of service the OIG is able to recommend that dollar impacts reflect the extrapolated error rates from their reviews. This is highly controversial because of financial magnitude and the approach to extrapolation. This marks one of the first ones that I have seen. In this audit the OIG reviewed 240 conditions from the years in question. There are 8 conditions that were reviewed during the audit. They were stroke, heart attack, embolism, sepsis, lung cancer, breast cancer, colon cancer, and prostate cancer. What jumps out to me in this review is the sepsis category. This is the first time I have seen sepsis as a high risk diagnosis. In fact, sepsis and pressure ulcers are in the other review (which I will post shortly). The story continues to be the same. Acute conditions being captured when they often represent historical conditions. In fact for the cancers, strokes, and heart attacks a whopping 93.3% (168 of 180) were found to not be valid. This is in line with prior reviews. Organizations, both payers and providers, must have processes in place to identify and review these. For the sepsis patients, 30% were rejected. While higher than desired, this is significantly lower than other targeted conditions the OIG historically reviews. The call to action for organizations is simple: 1) Know your data- know what patients you have, what conditions they have, and what you are billing for your patients. 2) Increase scrutiny on high risk conditions- if a patient has a stroke, heart attack, or cancer that is captured by a PCP or captured only once in a calendar year it is worth a second review. 3) Educate providers- it is critical to educate providers on the difference between active conditions and historical conditions. There is often no ill intent by providers rather it is matter of coding appropriateness. Leverage your experts to help them know the rules. Enjoy your Wednesday! https://lnkd.in/eX7tjgyB

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