Addressing Your Office Procedures to Combat the Perception of Fraud

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The Fraud Prevention System (FPS), implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011, uses models that predict suspicious behavior with the goal of preventing the payment of fraudulent claims. This system has saved the federal government millions of dollars. For example, in fiscal year 2016, CMS reported that 90 providers had their payments suspended because of investigations initiated or supported by FPS, which resulted in an estimated $6.7 million in savings.

The FPS analyzes claims to identify health care providers with suspect billing patterns. While some of those payments are related to potential fraud, others may be highlighted from simple in-office mistakes – like misidentifying the place where service was rendered. Those mistakes may be highlighted as potential fraud and spur government contractors to triage the leads faster – taking valuable administration time from you to refute the investigation.

As an example, your office may automatically rebill for a patient, and the billing may appear in CMS’ system as a deliberate attempt for duplicate payment. Your office could receive a letter from either a Zone Program Integrity Contractor (ZPIC) or a Unified Program Integrity Contractor (UPIC) about the potential fraud. In that case, you should contact your practice attorney immediately to address this. (See below for contactor names.)

Business offices should ensure they have proper coding and documentation for all services before the claim is submitted to CMS, as well as a review process for denials so claims are not automatically re-submitted.

NOTE:  The independent UPIC/ZPIC contractors are:

  • Safeguard Services (SGS): CA, HI, NV, American Samoa, Guam, Mariana Islands

  • AdvanceMed: WA, OR, ID, UT, AZ, WY, MT, ND, SD, NE, KS, IA, MO, AK

  • Cahaba: MN, WI, IL, IN, MI, OH, KY

  • Health Integrity: CO, NM, TX, OK

  • AdvanceMed: AR, LA, MS, TN, AL, GA, NC, SC, VA, WV

  • Under Protest: PA, NY, DE, MD, DC, NJ, MA, NH, VT, ME, RI, CT

  • Safeguard Services (SGS): FL, Puerto Rico, Virgin Islands  

This information was taken from the InfoDive Coding and Audits webinar held in November 2018.