Program Integrity Compliance Solution
Med-Prov, LLC is led by Healthcare Attorneys, Health Care Policy Experts possessing Strong Clinical and Analytic Skills. We collaborate with a variety of health care professionals and Government agencies to combat Fraud, Waste, and Abuse across vast governmental programs.
The False Claims Act—embodied in U.S. Code Title 31, Chapter 37, Subchapter III—prohibits the submission of “knowing” false claims to obtain federal funds. The United States may sue violators for treble damages (three times the government’s loss), plus $5,000 to $10,000 per false claim. The law is not limited to claims submitted with fraudulent intent or actual knowledge of their falsity. It also applies to “ostriches with their heads in the sand” who make false claims with “deliberate ignorance” or “reckless disregard” of truth or falsity, or “gross negligence.”
Our seasoned clinicians and analysts were instrumental in detecting over $10,00,000 in aberrant Medicare claims allowing us to work with the community to continue to protect the Medicare Trust Fund. Our success is primarily due to strong collaboration with our customers and other stakeholder to make sure Program requirements are clearly understood and are effectively adoptable. We believe the best way Fraud, waste, and abuse can be materially reduced is through prevention, self-assessments and frequent awareness training and education programs, because IGNORANCE is No Defense.
Our success is primarily due to strong collaboration with our customers and other stakeholder to make sure Program requirements are clearly understood and are effectively adoptable.
For Years the steadily growing problem of healthcare fraud has attracted attention at the federal level. The Federal Government allocated billions of dollars to support the Health Care Fraud and Abuse Control program, which is designed to coordinate federal, state, and local law enforcement activities. The Healthcare Fraud Prevention and Enforcement Action Team, a combined effort of the Departments of Justice and Health and Human Services announced in May 2009, that they too will address fraud and abuse.
What Does this Mean to Providers?
- Increased Audits and Reviews
- Increased Pressure to improve Controls, and
- Manage Risks for the Practice.
Our goal is to work with customers to reduce risks and eliminate burdens using proactive approaches such as; Awareness, Risk Assessments, Risk Management and Quality Management.
We are a Policy-Driven Clinical and Analytical Group with substantial experience supporting Plans, CMS, State Medicaid, and Providers
We believe that Healthcare fraud and abuse may persist-and even worsen-as hospitals and providers continue to adopt electronic health records (EHRs), As technology changes, those who intend to commit fraud are always going to be one step ahead of those who are trying to detect it. That’s because EHRs make it easy for thieves to fabricate information. For example, providers can easily produce fraudulent yet credible claims by creating virtual episodes of care that fly completely under an insurer’s radar, Identity theft of both patients and providers is also a likely possibility. These are just two examples of how easy it is to commit fraud in an electronic environment-all with the simple click of a mouse. Med-Prov is skilled in the areas of data management and data manipulation-both of which play a vital role in fraud detection and tracing aberrant data patterns over time. In addition, we use behavioral and forensic technology along with audit trail analysis to identify fraud and vulnerabilities. Profiling and Pattern Analysis is a key component to detect precision based discrepancies and reduce provider burden.
The False Claims Act—embodied in U.S. Code Title 31, Chapter 37, Subchapter III—prohibits the submission of “knowing” false claims to obtain federal funds. The United States may sue violators for treble damages (three times the government’s loss), plus $5,000 to $10,000 per false claim. The law is not limited to claims submitted with fraudulent intent or actual knowledge of their falsity. It also applies to “ostriches with their heads in the sand” who make false claims with “deliberate ignorance” or “reckless disregard” of truth or falsity, or “gross negligence.”
Solution Services
- Subpart 3.10 – Contractor Code of Business Ethics and Conduct
- False Claim Act: U.S. Code Title 31, Chapter 37, Subchapter III
- Review Billing Practices
- Medical Review/Documentation
- Claim Review
- EHR Audit and Review
- Clinical Coding Audit and Review (CPT, ICD-10, HCPC, and more)
- Data Analysis
-Descriptive/Predictive/Prescriptive
-Forensic Analysis
-Behavioral Intelligence Unit - Self-Assessments/Education and Training
- Risk Assessment/Risk Management
-Vulnerability Studies - Conflict of Interest
- OIG Corporate Integrity Agreement Legal Support
- HIPAA Privacy and Security
- Medicare and Medicaid Program Integrity
-False Claim Act
–Fraud, Waste, Abuse – Overpayment Detection - Starks/Anti Kick-Back
- LTC MEGA Rule
-SAMSAH Program
-Accountable Care Organization
-Hospitals Based Review
-Individual Practice
-Pharmacy Audit and Review