When Special Investigation Units (SIUs) and Payment Integrity (PI) teams think of durable medical equipment (DME) fraud, classic schemes often come to mind: unnecessary brace shipments and telemarketing lead-generation mills. But as analytical defenses grow sharper,...
A major maternity coding change is due January 1, 2027—and it is much more than a routine annual update. The American Medical Association (AMA) is deleting the traditional global obstetric CPT structure and moving to separate reporting for four phases of care:...
Telehealth billing remains complex as payer requirements continue to vary across procedure codes, modifiers, and places of service. Medicare, Medicaid, and commercial plans may apply different billing expectations, creating risk when providers use a uniform approach...
Risk adjustment involves billing diagnosis information that is properly supported in the medical record. It estimates the expected annual cost of care and aligns payments to the complexity of a patient’s conditions. Because payments rise with diagnosis severity, an...
Recent actions by the Centers for Medicare & Medicaid Services (CMS), including targeted spending reviews and the Comprehensive Regulations to Uncover Suspicious Healthcare initiative, known as CRUSH, reflect a measurable shift in federal oversight expectations....
