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Provider Compliance - Submission of Accurate Claims and Information Dashboard
Medicare Healthcare Provider
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Overall Assessment
 
Assessment
Like
Sig
IRR
Ctrl Eff
Conc
Rsk
RF Rsk
RRR
 Residual Risks Risk Response
Provider Compliance - Submission of Accurate Claims and Information  Reasonably Possible Moderate Moderate Adequate Moderate Moderate Moderate
 
Scheme Assessment
 
Scheme
Like
Sig
IRR
Ctrl Eff
Conc
Rsk
RF Rsk
RRR
 Residual Risks Risk Response
Billing - Improper Coding  Reasonably Possible High High Adequate Moderate Low Moderate
Billing - Misrepresentations 
Billing - Non-Covered Services  Reasonably Possible High High Adequate Moderate Low Moderate
Billing - Patient not present  Reasonably Possible High Moderate Adequate Moderate Low Moderate
 
Scenario Assessment
 
Billing - Improper Coding - Scheme
Scenario
Like
Sig
IRR
Ctrl Eff
Conc
Rsk
RF Rsk
RRR
 Residual Risks Risk Response
Clustering Reasonably Possible High High Fair Low Low Moderate
Coding medically unnecessary services as required
DRG creep
Duplicate claims Probable
Incorrect use of codes that are related (unbundling) or mutually exclusive Probable High High Fair Moderate Low High
Upcoding Reasonably Possible Moderate Moderate Strong Moderate Low Low
 
Billing - Patient not present - Scheme
Scenario
Like
Sig
IRR
Ctrl Eff
Conc
Rsk
RF Rsk
RRR
 Residual Risks Risk Response
Billing for services not provided - Using existing patient names Reasonably Possible Low Moderate Fair Moderate Low Moderate
Billing for services not provided - Using phantom or deceased persons' names Reasonably Possible High Moderate Fair Moderate Low Moderate
 
 
 
   
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