40 results.
Fraud and Abuse Implications for the HIM Professional
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....
Fraud and Abuse: What You Can Do
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....
Coding Compliance: Practical Strategies for Success
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....
Advocating for Quality Documentation and Adherence to Official Coding Guidelines
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....
Playing a Part: The FBI's Role in Healthcare Fraud Investigations
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.
Benchmarks as the Signposts Along the Fraud Case Trail
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....
In Pursuit of Healthcare Fraud
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....
Honest Mistake or Fraud? Meeting the Coding Compliance Challenge
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....
Corporate Compliance: A Look at the Hot Issues and Current Trends
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....
Is the FCA Effectively Fighting Healthcare Fraud?
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....
Observation Services Present Compliance Challenges
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....
PHI Audits: the Global Use of Protected Health Information in Organized Crime. Is Your Organization Ready?
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....
Diagnosis Coding and Medical Necessity: Rules and Reimbursement
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....
Room for Improvement: CMS Reports 2004 Payment Error Rate Findings; OIG Publishes Recommendations for Hospital Compliance Programs
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....
Report on the Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities
Author: AHIMA
Source: AHIMA Foundation
Publication Date: September 30, 2005
Reports: Health IT Can Address Healthcare Fraud
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....
Fighting Fraud Automatically: How Coding Automation Can Prevent Health Care Fraud
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....
Fraud Control: New Tools, New Potential
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....
Fraud Management: a $100 Billion Bonus from Health IT?
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....
Dangerous E/M Coding Practices: Identifying and Remedying Common Sources
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.....
Ready for the Deficit Reduction Act?: Effective 2007, the Federal Government is Raising the Bar on Anti-Fraud Compliance
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....
Guidelines for EHR Documentation to Prevent Fraud. Appendix A: Resource List
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.
Guidelines for EHR Documentation to Prevent Fraud
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.
Brailer to HIM: Continue 'Larger, Louder, and Faster'
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....
Linking Anti-fraud and Legal EHR Functions
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....
Recommended Requirements for Enhancing Data Quality in Electronic Health Record Systems: Final Report
Author: RTI International
Source: Government (U.S.)
Publication Date: May 02, 2007
RHIOs: Build in Healthcare Fraud Management from the Beginning
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....
Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk
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....
Walking the Tightrope—Coding Compliance in the Electronic Age
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....
Medicare: Improvements Needed to Address Improper Payments in Home Health
Author: U.S. Government Accountability Office
Source: Government (U.S.)
Publication Date: February 27, 2009
Framework For Combating Fraud, Waste, And Abuse In Federal Health Care Programs
Author: Morris, Lewis
Source: Government (U.S.)
Publication Date: April 22, 2009
Fraud Enforcement and Recovery Act of 2009
Author: U.S. Congress
Source: Government (U.S.)
Publication Date: May 20, 2009
Stop Medicare Fraud [external web site]
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.
Study of Health Care Fraud and Abuse: Implications for Professionals Managing Health Information
Author: AHIMA Foundation
Source: AHIMA report
Publication Date: November 2010
Stopping Fraud: Detecting and Preventing Fraud in the e-Health Era
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.
....
Understanding Governmental Audits
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.
Predictive Modeling 101: How CMS’s Newest Fraud Prevention Tool Works and What It Means for Providers
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....
Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update)
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....
Understanding Governmental Audits (2013 update)
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....
Preventing Fraud and Abuse in Clinical Documentation
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:....