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Join us in Chicago!  |
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National Workers' Comp & Disability Expo November 6-8, 2007 |
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Maryland, Nevada, New Mexico, Oregon and Pennsylvania have all been added to the BillChek service area! Want to get better savings in these states? Contact your account manager or call Customer Service at (800) 833-1993 and start today! |
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| Volume 9/Fall 2007 |
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Qmedtrix unveils Fraud and Abuse service Provider and billing pattern profiling is at the root of Qmedtrix’s new Fraud and Abuse service, which utilizes algorithms to identify and review bills suggestive of fraudulent charges. The latest BillChek service addition was announced earlier this month after having completed the required due diligence to assure the same defensibility standards as all other BillChek services. The service centers on validating provider physical and billing addresses, as well as verifying the provider is a valid business entity, is licensed to provide medical services and have no sanctions or medical board actions that prohibit the performance of the billed services. Continuous data analysis and new technology allows the Fraud and Abuse service to evolve as new areas of fraud and abuse emerge. Beta testing of the new service demonstrates how severe fraud has become. Consider this case: A California ASC submitted 6 bills totaling $80,309.84 using an Arizona billing address. The bill was paid in full as if the provider had provided the service in Arizona and was therefore exempt from the California ASC fee schedule. The fee schedule reimbursement would have been $24,353.27. Qmedtrix’s Fraud and Abuse service could have saved this payor $55,956.57. Another case illustrates the importance of provider and billing pattern profiling: A provider billed for an epidural catheter on over 60% of non-back surgical procedures, an unusually high rate when compared to peer data of 26%. A detailed review revealed that a pain pump was used rather than a catheter. Pain pumps are included in the global reimbursement, rather than paid separately. National Institute of Health Awards Grant The National Institute of Health (NIH) awarded Qmedtrix $94,000 in federal funding for the development of mathematical algorithms to detect fraud and prevent improper Medicare payments. The U.S. Government Accountability Office estimates that Medicare’s improper payments to providers exceed $21 billion yearly. In 2005, authorities discovered a single hospital system had billed Medicare over $1 billion in fraudulent charges alone. Merrit Quarum, M.D., president and CEO of Qmedtrix, said the best fraud detection system determines if the claim is valid before it determines the appropriate reimbursement, and that mathematics becomes a fundamental part of the equation as fraud and abuse schemes get progressively deceitful and egregious. Qmedtrix will apply for $750,000 in additional funding when the project’s initial phase is completed in six months. For more information regarding this exciting development, visit New Year, New Look! Qmedtrix has been working hard this year—hiring new people, adding new services and performing new research. What better way to finish the year than with a brand new look? Watch for Qmedtrix to start rolling out our vibrant new look in 2008, but you can get a sneak peak at either of the upcoming conferences in Chicago. Come see us! Questions or comments? Visit our web site, contact your account manager or call Customer Service at (800) 833-1993.
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