Medicare Fraud and Abuse

The Federal government has passed laws designed to mitigate the effect of fraud and abuse within the Medicare system.  According to the Centers for Medicare & Medicaid Services, healthcare provider fraud and abuse causes billions of dollars of wasteful spending within the Medicare program.  The efforts to reduce waste are far reaching and these efforts impact healthcare providers throughout the country.  The Martin Law Firm’s healthcare attorneys represent many of these providers facing claims of fraud and/or improper billing which can lead to recoupment of amounts received by the provider for services rendered or revocation of billing privileges.


Fraud and Abuse – Improper Claims Payments

Since 1996, the Centers for Medicare & Medicaid Services (CMS) implemented a number of programs to prevent improper claim payments.  Some of these programs are aimed at identifying improper claims before payment is made and some are designed to identify and recoup improper payments after a claim is processed.  One CMS report concluded that 7.8 percent of Medicare dollars paid to health care providers did not comply with one or more Medicare rules for coding, billing or payment, which equates to over $24.1 billion in Medicare overpayments and underpayments annually.


National Correct Coding Initiative (NCCI)

NCCI is intended to promote national correct coding methodologies and to control improper coding that leads to inappropriate payments in Medicare claims. These coding policies are based on CPT, HCPCS, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice.
NCCI edits are automated prepayment edits to track whether a submitted claim complies with NCCI policy.  If a claim submitted does not comply, then the claim is denied.  Since this type of denied claim is a coding denial, the provider cannot get paid from the patient/beneficiary even if an ABN form is used.


Medicare Unlikely Edits (MUE)

MUEs are also automated.  They are unit of service edits.  An MUE for a specific code is the maximum number of units of service under most circumstances that a provider would report for that code for one patient on one date of service.  CMS will not publish most MUE values because it could lead to providers taking advantage of it, raising further concerns. A denied claim from because of the MUE can be appealed.
These are just some of the enhanced mechanisms that CMS and its contractors utilize.  Other common ways that CMS challenges healthcare providers and their billing/claims are through random sampling and claims reviews, audits, claim data analysis, complaints from patients, and so on.


Medicare Fraud and Abuse Attorneys

The Martin Law Firm provides compliance guidance for all healthcare provider types including, but not limited to physicians, chiropractors and physical therapists.  If CMS or a Medicare contractor has initiated an audit or suspect fraud and abuse from you and your practice, it is important for you to contact the Medicare attorneys at The Martin Law Firm immediately.