Understanding NCCI Edits

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for …

Health Care Fraud – Don’t Do It!

If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don’t need to tell you this. 
I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate …

Understanding ZPIC

The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone.   Links are provided for each zone which contains information about each zone as well as activity and updates in those regions. 



States in Zone

Safeguard Services (SGS)


California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands

Health Integrity
(subcontractor …

Understanding RAC

Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries.  This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.   RAC began in 2005 as a three-year demonstration project consisting …

Healthcare Fraud Investigations in FY 2013

Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 …