Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: April 1997

Healthcare Fraud and Abuse Legislation

On August 21, 1996, President Clinton signed into law the Health Insurance Portability and Accountability Act. This law addresses several issues including the creation of a Health Care Fraud and Abuse Control Program. This program is intended to com....

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: January 1998

During AHIMA's National Convention, HIM professionals convened to network and share practical ideas on issues pertaining to fraud and abuse. While most of the participants worked in hospitals, other work settings, including colleges, consulting firms, and government agencies were als....

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: January 1998

"Fraud," "abuse," "upcoding," "unbundling," and "compliance" have all become buzzwords in the news media. Eliminating healthcare fraud and abuse has become a top priority for the federal government. Government investigations are on the rise and providers everywhere tremble at the thought of b....

Author: AHIMA House of Delegates

Source: Journal of AHIMA | AHIMA HoD Resolution

Publication Date: January 1998

Background

In August 1996, the Health Insurance Portability and Accountability Act (HIPAA) [Public Law 104-191] established the infrastructure and funding for federal fraud and abuse efforts. This legislation authorizes the appropriation of $104 million in 1997, with increases in....

Author: King, Ellen

Source: Journal of AHIMA

Publication Date: January 1998

Healthcare fraud is a multibillion dollar problem costing every taxpayer significant amounts of money. Fraud also jeopardizes the health and safety of patients. It has been estimated that fraud accounts for about one-tenth of the $1 trillion spent annually on healthcare.

Author: Kaldal, Karen

Source: Journal of AHIMA

Publication Date: November 1998

Traditionally, payers in the healthcare industry have relied on external tips or complaints for starting points for fraud investigations. But recently the number of leads on fraud activity has increased as the public becomes more aware of the issue. To combat this problem, payers have begun to....

Author: King, Ellen

Source: Journal of AHIMA

Publication Date: January 1999

How broad is the scope of healthcare fraud and abuse? Here's a look at the many ways the Federal Bureau of Investigation is tackling the problem.

Healthcare fraud takes billions of dollars away from federally funded healthcare programs. These programs, particularly Medicare and Med....

Author: Averill, Richard F.

Source: Journal of AHIMA

Publication Date: May 1999

The implementation of a comprehensive compliance program requires the participation of many hospital departments, including medical records, billing, admitting, finance, and legal.1 The component of a compliance program that most directly affects the HIM professional is coding compliance. For....

Author: Prophet, Sue

Source: AHIMA Convention

Publication Date: October 10, 2001

Under the new federal administration, no fundamental changes in healthcare fraud enforcement efforts are anticipated. Federal enforcement initiatives have resulted in significant monies being recovered and returned to the Medicare Trust Fund through collection of overpayments and civil penaltie....

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: May 2002

How effective has the False Claims Act (FCA) been in reducing healthcare fraud? A recent six-month study conducted by New Directions for Policy for Taxpayers Against Fraud sought to determine just that.1 What the study found is that the FCA is very effective in fighting fraud and should not be....

Author: Prophet-Bowman, Sue

Source: Journal of AHIMA

Publication Date: March 2003

Observation services have been a top fraud and abuse target of the Office of Inspector General (OIG) of the Department of Health and Human Services, primarily due to the complexity of the Medicare billing regulations and the potential for abuse. New regulations regarding reimbursement for thes....

Author: Busch, Rebecca S.

Source: AHIMA Convention

Publication Date: October 15, 2004

Organized crime is defined by The Oxford English Dictionary as: "of or pertaining to a coordinated criminal organization directing operations on a large or widespread scale."1 The term was first used and noted in a book called Organized Crime in Chicago , published by the Illinois Association....

Author: Cogley, Janis

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

The origins of using diagnosis codes in hospitals and other healthcare settings goes back to the early 1950s when the US Public Health Service and the Veterans Administration extended the concept of using the International Classification of Diseases to hospital indexing of m....

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: April 2005

Two recent developments highlight the need for improvement in medical record documentation, coding, and hospital compliance programs.
CMS Fails to Meet 2004 Payment Error Rate Performance Goal

One of the Centers for Medicare and Medicaid Services’ (CMS) Medicare performan....

Author: AHIMA

Source: AHIMA Foundation

Publication Date: September 30, 2005

Author:

Source: Journal of AHIMA

Publication Date: January 2006

FORE Reports Announced at Press Conference

National Health Information Technology Coordinator David Brailer, MD, PhD, thanked AHIMA for “a landmark effort” during a press conference highlighting the release of two reports detailing how health information technology can ad....

Author: Garvin, Jennifer Hornung; Watzlaf, Valerie J.M.; Moeini, Sohrab

Source: Journal of AHIMA

Publication Date: March 2006

Automation helps streamline the coding process. When combined with sophisticated analytic software, it can reduce fraud, too.

Automating coding software is generating interest for many reasons--an important one is its ability to speed the turnaround time between patient enco....

Author: Hanson, Susan P.; Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: March 2006

With the right planning, health IT and nationwide health data exchange can deter healthcare fraud.
Fraud is a significant drain on the US healthcare system. The National Health Care Anti-Fraud Association estimates that 3 percent of the nation's annual healthcare outlay--$51 billion--was....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2006

The financial losses from healthcare fraud in the US are staggering...and growing. Fraud was estimated to be between 3 and 10 percent of total health expenditures in 2003, or $51 to $170 billion, according to the National Health Care Anti-Fraud Association. Whether an interconnected health IT....

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: March 2006

Code assignment for physician evaluation and management (E/M) services is inherently problematic because of the multiple coding rules and reporting guidelines that must be applied and the subjectivity of the codes. Consistent E/M coding practices are critical in the physician practice setting.....

Author: Sheeder, Frank

Source: Journal of AHIMA

Publication Date: October 2006

Large providers dozing on January 1 will put their Medicaid reimbursement at risk. But it will not take long before new federal anti-fraud mandates become universal requirements or voluntary practices for providers of all sizes.
On February 8, 2006, the president signed the Deficit Redu....

Author: AHIMA e-HIM Work Group: Guidelines for EHR Documentation Practice

Source: AHIMA web extra

Publication Date: January 02, 2007

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: AHIMA e-HIM Work Group: Guidelines for EHR Documentation Practice

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2007

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author:

Source: Journal of AHIMA

Publication Date: January 2007

“Do what you are doing larger, louder, and faster,” David Brailer, PhD, MD, told attendees during his general session presentation. Brailer, who served as national coordinator for health information technology in the Department of Health and Human Services from 2004 to 2006, thanked the audienc....

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: March 2007

The following statement could easily come from any material written on the legal electronic health record: “EHRs and information available through the NHIN [nationwide health information network] must fully comply with applicable federal and state law and meet the requirements of reliability an....

Author: RTI International

Source: Government (U.S.)

Publication Date: May 02, 2007

Author: Hanson, Susan P.; Cassidy, Bonnie S.

Source: AHIMA Convention

Publication Date: October 10, 2007

The problem of fraud and abuse within the healthcare system comes from two sources: providers and patients. A provider is anyone who is authorized to give care by the Secretary of the Department of Labor.6
The types of provider fraud are numerous and vary in magnitude. Provider fraud and....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2008

Electronic documentation habits such as copy and paste save valuable time, but they can ruin the record.

As the patient’s health worsened, a hospital stay of days turned to weeks. But through the various tests and physician visits, the progress notes generated in the hospita....

Author: Williams, Vickie J.

Source: AHIMA Convention

Publication Date: October 17, 2008

Introduction

For at least the last ten years, the federal government and private whistleblowers have viewed improper diagnostic coding as fertile ground for major investigations and prosecutions of healthcare providers. Prosecutors use the civil False Claims Act, the Civil Money Penalties....

Author: U.S. Government Accountability Office

Source: Government (U.S.)

Publication Date: February 27, 2009

Author: Morris, Lewis

Source: Government (U.S.)

Publication Date: April 22, 2009

Author: U.S. Congress

Source: Government (U.S.)

Publication Date: May 20, 2009

Author: U.S. Department of Health and Human Services; U.S. Department of Justice

Source: Government (U.S.)

Publication Date: July 15, 2009

Medicare fraud results in higher health care costs for everyone. Eliminating fraud cuts costs for families, businesses, and the federal government. It also increases the quality of services for those who need care.

Author: AHIMA Foundation

Source: AHIMA report

Publication Date: November 2010

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2011

Stopping fraud will require health record systems, organizations, and individuals capable of, and committed to, detecting and preventing false claims before they are paid.

Healthcare fraud continues to plague the country, costing the United States billions of dollars per year.
....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2011

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: White, Susan E

Source: Journal of AHIMA

Publication Date: September 2011

In July the Centers for Medicare and Medicaid Services (CMS) began applying predictive modeling techniques to Medicare claims data to detect fraud. CMS contracted with Northrop Grumman, an information solutions company, to develop the technology. Northrop Grumman partnered with Verizon and Nat....

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: August 2013

Editor’s note: This update replaces the 2007 practice brief “Guidelines for EHR Documentation to Prevent Fraud.”


Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancin....

Author: Rihanek, Theresa; Lopez, Doreen

Source: AHIMA practice brief

Publication Date: November 2013

This practice brief supersedes the July 2011 practice brief "Understanding Governmental Audits."


Today, armed with enhanced fraud and abuse laws, the federal government has launched new audits that organizations and providers must contend with on a regular basis. Recent additions....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 2015

The HIM Problem: The US Department of Health and Human Services’ Office of the Inspector General (OIG) is expected to increase enforcement activities surrounding clinical documentation and fraud. Training and awareness are key in preventing penalties.


The HIM Problem Solver:....