 | | | | | | | | | | | | | | | | | | | | |
 |  | Provider Compliance - Submission of Accurate Claims and Information perform assessment |
 |  |  | Coding & Billing Environment perform assessment |
| |  | Billing - Non-Covered Services perform assessment |
| | | Billing - Misrepresentations perform assessment |
| | | Billing - Improper Coding perform assessment |
|  | | Billing - Patient not present
perform assessment |
| | |  | Billing for services not provided - Using existing patient names perform assessment |
| | | | Billing for services not provided - Using phantom or deceased persons' names perform assessment |
| | | |  | Red Flags |
| | | | | | Patient File Missing perform assessment |
| | | | | |  | Perform review of selected patient files perform assessment |
| | | | | | Patients receiving routine treatment live signficantly outside of service area perform assessment |
| | | | | | Patient File Does Not Agree with Billing Records perform assessment |
| | | | | | | Perform review of selected patient files perform assessment |
| | | | | |  | Test patient files perform assessment |
| | | | | | Insured's address on claim form is the same as provider perform assessment |
| | | |  | Controls |
| | | | | | Reconcile Patient Files to Billing Records perform assessment |
| | | | | | Billing Records Reconciled to Payments Received perform assessment |
| | | |  | Concealments |
| | | | | | Fictitious patient payments diverted to secondary bank accounts perform assessment |
| | | | | | Fictitious patient claims processed on secondary system perform assessment |
| | Provider Compliance - Reasonable and Necessary Services perform assessment |
| | Provider Compliance - Documentation and Reporting perform assessment |
| | Provider Corruption perform assessment |
| | Hospital Compliance - Submission of accurate claims and Information perform assessment |
| | Hospital Compliance - Statutes perform assessment |
 | | Hospital Compliance - Cost Reporting perform assessment |
