2 min read

Spotlight on March's Revenue Cycle Management Blogs

By Prime Care Tech Marketing on Thu, Mar 31, 2016 @ 06:45 PM

Revenue-Cycle-Management-Blog-Spotlight-322x221.jpgThis month’s revenue cycle management blogs explored a number of topics, including the basic concepts of a claims clearinghouse, how to ensure managed care claims flow smoothly, 3 ways to help your back office runs smoothly, and 8 ways to avoid False Claims Act pitfalls. Here are some highlights from each and links to access each blog in full.

Clearinghouse 101 – a re-introduction to automated claims processing

“Clearinghouse 101” – an introduction to the some of the critical features and benefits of a claims clearinghouse. Whether you are using one today or not, take a peak. You may find some of the tips useful.

Back to the basics.

Ensure Managed Care claims flow smoothly

Partnering with a clearinghouse with connections to thousands of payers makes submitting claims easier and revenue moving.  Keeping cash flow in a steady stream means understanding how managed care works – knowing the systems, procedures, and requirements are critical. A clearinghouse, like primeCLAIMS, has the ability to connect with multiple Managed Care payers, helps to ease the transition into Managed Care and your revenue cycling.

Learn how.

3 ways to make sure the back office is running smoothly during absences

Interruptions, urgent requests, and unanticipated call-ins, even scheduled absences can be disruptive. But retreat is not the answer. Substitute is the better option - making sure that others are trained to cover the important aspects when needed.

Discover how.

The False Claims Act: 8 ways providers can avoid penalties and fines

Periodically, you will see settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed medically necessary, do not meet coverage qualifications, or medical record indicates they were not provided as ordered.

How to avoid them.

Moving the Revenue Needle with Secondary Claims


Topics: clearinghouse False Claims Act managed care claims back office managed care
2 min read

The False Claims Act: 8 ways providers can avoid penalties and fines

By Prime Care Tech Marketing on Thu, Mar 03, 2016 @ 07:00 PM

iStock_000081024321_Small.jpgPeriodically, you will read about out-of-court settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed to be medically necessary, do not meet the coverage qualifications, or the medical record indicates they were not provided as ordered.

To take the side of an honest mistake, providers can find themselves inadvertently on the wrong side of the False Claims Act if medical record documentation does not support the following:

  • A medically necessary admission to a SNF within 30 days of a covered inpatient hospital stay lasting no less than three days,
  • That the resident/patient is receiving services and treatments for the condition or injury treated during the qualifying inpatient hospital stay,
  • The physician’s certification and subsequent recertification that the services ordered meet each of the qualifying requirements, and
  • The documentation identifies that the physician-ordered services were provided as ordered

Further, in an article written in April 2013, Amy E. McCracken wrote that providers must safeguard that claims filed do not include “worthless services” or “implied false certifications,” the two primary theories for the basis of liability. Worthless services suggests deficient services provided inconsistent with physician orders. Implied false certification infers the violation of Medicare or Medicaid regulations.

What are the potential damages? The False Claims Act provides for three times the actual damages and an $11,000 per-claim fine. This can add up quickly. In a recent McKnight’s article, a large provider agreed to pay $600K to resolve False Claims Act allegations. In this case, the facility in question failed to “provide patient care activities as recorded in the resident medical record of a patient and not providing certain care activities consistent with a physician order for more than a month.”

Also, in the case above, the provider has to “pay for a transition consultant to assist the new operator of the skilled nursing facility for a year. This consultant will help ‘identify risks and opportunities for improvement in providing skilled nursing services to residents at the facility.’”

What must providers do to minimize the risk of falling afoul of the False Claims Act?

  1. Confirm that the attending physician certifies and then appropriately recertifies the need for skilled care under the definition of skilled services within the SNF.
  2. Make sure the care plan is consistent with physician orders.
  3. Follow the care plan.
  4. Validate that the clinical documentation supports the services provided consistent with the care plan.
  5. Reconcile the clinical notes to make sure all disciplines, for example, nursing and rehabilitation, accurately and collaboratively support the resident’s/patient’s condition absent conflict or inconsistencies.
  6. Verify that the charges claimed are consistent with the documented physician-ordered services.
  7. Take advantage of the triple check process to confirm consistency of charges on the claim with the medical record, care plan, and physician orders. A mere typo can trip you up.
  8. Consider self-reporting. If you discover serious billing problems, voluntarily reporting the violation within 30 days of discovery may reduce and damages and penalties significantly.

Violating the False Claims Act carries with it heavy penalties to your hard-fought-for reputation and your finances. Take appropriate steps to minimize the risks. To do nothing would be cents-less.

Topics: False Claims Act medically necessary admission care plan physician-ordered services qualifying inpatient hospital stay certifications and recertifications penalties and fines


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