 | | | | | | | | | | | | | | | | | | | | |
 |  | Provider Compliance - Submission of Accurate Claims and Information edit |
 |  |  | Coding & Billing Environment edit |
| |  | Billing - Non-Covered Services edit |
| | | Billing - Misrepresentations edit |
| | | Billing - Improper Coding edit |
|  | | Billing - Patient not present edit |
| | |  | Billing for services not provided - Using existing patient names edit |
| | | | Billing for services not provided - Using phantom or deceased persons' names edit |
| | | |  | Red Flags |
| | | | | | Patient File Missing edit |
| | | | | | Patients receiving routine treatment live signficantly outside of service area edit |
| | | | | | Patient File Does Not Agree with Billing Records edit |
| | | | | |  | Perform review of selected patient files edit |
| | | | | |  | Test patient files edit |
| | | | |  |  | Link or Unlink an
Audit Procedure
or
Test to this Red Flag... |
| | | | | | Insured's address on claim form is the same as provider edit |
| | | |  | Controls |
| | | | | | Reconcile Patient Files to Billing Records edit |
| | | | | | Billing Records Reconciled to Payments Received edit |
| | | | | |  | Associated Parties |
| | | | | | | Review reconcilation of payments to bank accounts edit |
| | | | | | | Link or Unlink a Insider,
Outsider,
Function,
Test
or
Audit Procedure
to this Control... |
| | | |  | Concealments |
| | | | | | Fictitious patient payments diverted to secondary bank accounts edit |
| | | | | | Fictitious patient claims processed on secondary system edit |
| | | | | Link or Unlink a
Insider,
Outsider,
Department,
Control,
Red Flag,
Concealment Strategy
to this Scenario... |
| | | | Link or Unlink a Scenario
to this Scheme... |
| | | Link or Unlink an Environment or a
Scheme
to this Assessment... |
| | Provider Compliance - Reasonable and Necessary Services edit |
| | Provider Compliance - Documentation and Reporting edit |
| | Provider Corruption edit |
| | Hospital Compliance - Submission of accurate claims and Information edit |
| | Hospital Compliance - Statutes edit |
| | Hospital Compliance - Cost Reporting edit |
| | Create a new Risk Assessment at this level... |
