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AAPC August 1, 2007
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Issue #82

Top Stories

OIG Releases Annual Report of Medicaid Fraud

CMS Clarifies Guidelines for "Other Than Clean Claims"

Study Finds That EHRs May Not Improve Quality of Care in Ambulatory Setting

Looking for Kudos!


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Torrey Kim

Torrey Kim, CPC
EdgeBlast editor

Top News

OIG Releases Annual Report of
Medicaid Fraud

Last month, the Department of Health and Human Services Office of Inspector General (OIG) released its Annual Report on the State Medicaid Fraud Control Units (MFCU), which outlined Medicaid fraud that the OIG discovered during fiscal year 2006. The fraudulent activities uncovered by MFCU in 2006 recovered over $1 billion.

For example, in one case, the OIG found that a Kentucky anesthesiologist billed for services that his pain management clinic didn't actually deliver. The physician also billed Medicare and Medicaid for a bioelectric device that wasn't federally approved. Because the physician's wife and father-in-law were involved, they were also sentenced. The physician had to pay back $350,000 to the government.

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CMS Clarifies Guidelines for "Other Than Clean Claims"

CMS clarified its rules for processing what it refers to as "other than clean claims" on July 20. According to CMS Transmittal 1312, Medicare must process such claims and let the provider who submitted the claims know of a determination within 45 days of the claim receipt.

According to the Transmittal, "Claims that do not meet the definition of 'clean' claims are 'other-than-clean' claims. 'Other-than-clean' claims require investigation or development external to the contractor's Medicare operation on a prepayment basis."

If the Medicare contractor has to contact the provider for additional information before it can process the claim, the carrier will stop counting the 45 days. When the carrier receives the requested materials back from the provider, the 45 day countdown will resume from where it left off.

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Study Finds That EHRs May Not Improve Quality of Care in Ambulatory Setting

According to a study published in the July 9, 2007 Archives of Internal Medicine, electronic health records (EHRs) may not be the cure-all that some experts originally suggested.

Five physicians authored the study, which scrutinized the link between EHR use and ambulatory care quality.

The study authors reviewed EHR usage and compared it against 17 ambulatory quality indicators. According to the authors, "Performance on quality indicators was defined as the percentage of applicable visits in which patients received recommended care."

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Looking for Kudos!

Have you performed your 100th prospective claims audit at your practice? Did you trek across Africa on safari? Have you recently filed appeals that brought in an extra $50,000 in revenue for your facility? We'd love to hear about it! Please submit your Kudos to our editors at kudos@aapc.com.

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Test Yourself - Earn .5 CEUs

By answering the following questions, you can earn .5 continuing education units to apply toward your AAPC certification renewal. Simply answer the questions and send in a copy of your work when submitting your CEU package or enter your CEUs into the CEU Tracker online. Include the number of each EdgeBlast on your submission (example: #82). The number is available at the top of the page.

Answers to the questions are not always found directly (word for word) in the EdgeBlast in which they appear. While often related to the EdgeBlast content, they require additional resources such as your ICD-9-CM, CPT® and HCPCS manuals.

1. How much did a Kentucky anesthesiologist have to pay back to the government for services he didn’t actually deliver?

Answer:

2. A recent study found that EHRs were used in what percentage of the 1.8 billion ambulatory visits in the U.S. during 2003 and 2004?

Answer:

3. According to a new Medicare Transmittal, what is the definition of an "other than clean claim?"

Answer:

4. How much did a Texas physician collect from Medicare and Medicaid for each preprinted certificate of medical necessity (CMN) that he signed for motorized wheelchairs?

Answer:

5. If a Medicare carrier receives an "other than clean claim," how many days does the carrier have to process the claim?

Answer:

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