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CMS Auditing Series 

Part III of IV

One of the primary objectives of healthcare reform is to reduce the continued rise in healthcare spending. With the passage of the Patient Protection and Affordable Care Act, enforcement against Medicare and Medicaid fraud and abuse and other improper payments has gained traction. This third installment of the CMS Auditing Series will examine a new methodology that CMS is utilizing to prospectively identify hospitals at high risk for fraud and abuse violations.  

  CMS Auditing Series: Identifying High Risk Hospitals 

On July 1, 2011, CMS began using predictive modeling software to identify hospitals at "high risk" for potential fraud and abuse. This new methodology may allow CMS to transition from "pay and chase" strategies to early detection of fraudulent claims - before payments are made. In part three of the CMS Auditing Series, this article examines the new CMS methodology for prospective identification of high risk hospitals. (Read more...) 

  2012 OIG Work Plan Released 

On October 5, 2011, the Office of Inspector General (OIG) released their 2012 fiscal Work Plan that providers may use as a glimpse into anticipated compliance trends and strategize accordingly. This year's plan focuses on many of the issues raised by the Patient Protection and Affordable Care Act, including increased fraud and abuse detection, resource allocation, and reimbursement efficiency. (Read more...) 

  CMS Bundled Payment Initiative: Four Models for Coordinated Care 

CMS recently announced a Bundled Payments Initiative that includes four models for bundling payments. One model includes a single prospective payment for all services provided during an inpatient stay, and three models include a retrospective payment system with a target price for an established episode of care. The Payment Bundling Initiative is expected to provide better outcomes in environments where physicians and hospitals have already established strong communication and collaboration. (Read more...)   

  Forced Transparency for Health Insurers 

On October 13, 2011, HHS launched a federally controlled webpage where consumers can discover whether an insurer has raised rates and for what reason. Several ACA provisions and the climbing cost of insurance premiums were the impetus for the website's design, which continues to increase transparency in healthcare. (Read more...) 

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