Credentialing and Audit Issues with Medicare, Medicaid, and Various Health Insurers

Currently, providers and suppliers of services to patients covered by Medicare, Medicaid, and third-party health insurers are being placed under heightened scrutiny and are becoming more likely to be subject to increased audits due to billing issues. The main focus of an audit is to provide evidence that health insurers have been properly billed for any medical service provided to patients. When a health insurer has reported an allegation of overpayment the health care provider will have the opportunity to appeal that allegation. The appeals process for an alleged overpayment can be a stressful and burdensome process. With the help of skilled attorneys, this process can go more smoothly and effectively. When Medicare, Medicaid or private insurers allege improper billing, it is important to be represented by legal counsel throughout the process.

The Centers for Medicare and Medicaid Services (CMS) are no longer in a “pay and chase” mindset but are actively trying to prevent fraud and illegality. Enrolled providers that abuse their billing privileges may get those privileges revoked. The most common reason for a healthcare business to have revoked billing privileges may include:

  • Noncompliance
  • Provider conduct
  • Felony conviction
  • False or misleading information on the enrollment application
  • On-site reviews
  • Provider screening requirements
  • Misuse of billing number
  • Abuse of billing privileges
  • Failure to report
  • Failure to meet documentation requirements
  • Home Health Agency capitalizationMedicaid termination
  • Prescribing authority
  • Improper prescribing practices

It is essential for healthcare businesses to implement policies and procedures that will deter health care providers from engaging in illegal billing procedures. This, in turn, will minimize the audit risks as well as any possible litigation.

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