Part B Insider (Multispecialty) Coding Alert
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Physician Notes: Upcoding and False Claims Continue to Garner Big Penalties from the OIG


- Published on Thu, Oct 26, 2017

Plus: The QRUR review period is “informally open,” according to CMS.

Upcoding is a focus area for the HHS Office of Inspector General (OIG), and often is the first offense that leads investigators to uncovering more serious crimes.

A recent Department of Justice (DOJ) case found Murfreesboro, Tennessee Podiatrist John J. Cauthon guilty of Medicare fraud after running a false-claims scheme between May 2014 and August 2015. Among his offenses were prescriptions for ankle braces that were medically unnecessary, routine foot care upcoded to nail avulsions, and the submission of claims for surgical procedures he never performed, said a DOJ brief.

“Cauthon is scheduled to be sentenced on January 26, 2018,” the DOJ release noted. “He faces up to 10 years in prison and a $250,000 fine for each count of health care fraud.”

Read about the DOJ case at: www.justice.gov/usao-mdtn/pr/murfreesboro-podiatrist-convicted-16-month-scheme-defraud-medicare-and-other-health.

In other news …

The review period to check your 2016 annual Quality and Resource Use Reports (QRURs) opened on Sept. 18 and will run through Dec. 1, 2017. The 2016 data, which is used to adjust Medicare payments under the Value Modifier program, ends in 2018 and was replaced on Jan. 1, 2017 by MIPS under the Quality Payment Program for the 2019 payment year.

“Authorized representatives of groups and solo practitioners can access the 2016 Annual QRURs and file an informal review on the CMS Enterprise Portal using an Enterprise Identify Data Management (EIDM) account with the correct role,” the CMS guidance says.

To find out more about informal review of your QRUR, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR.html.






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