CMS sets up real-time medical fraud center with DOGE; Federal contractor rolls out commercial tool

Published: Fri, 05/02/25

Updated: Fri, 05/02/25

Link to all things medical coding & billing

CMS sets up real-time medical fraud center with DOGE; Federal contractor rolls out commercial tool

The Centers for Medicare & Medicaid Services (CMS) has launched the Fraud Detection Operation Center (FDOC) to fight waste, fraud and abuse, the agency announced this week. Listed on a new webpage are a list of “recent success stories.” They include taking action against improper enrollment in Affordable Care Act (ACA) plans, cracking down on false billing of...

Breaking the ‘intellectual bottleneck’: How AI is computing the previously uncomputable in healthcare

Whenever a patient gets a CT scan at the University of Texas Medical Branch (UTMB), the resulting images are automatically sent off to the cardiology department, analyzed by AI and assigned a cardiac risk score. In just a few months, thanks to a simple algorithm, AI has flagged several patients at high cardiovascular risk. The CT scan doesn’t have to...

The Comprehensive CDI Report

As the healthcare industry changes, there needs to be a shift from a growth perspective to an efficiency perspective. Most hospitals had their highest case mix index (CMI) during COVID, but most also had negative margins. What COVID confirmed is that CMI is not a great measure, because a hospital can have a very high CMI and still be losing money. It is far...

Taking the Pain out of Pain Coding – Part I

Continuing with our look at areas of coding confusion, let’s today examine pain. According to Medline Plus Magazine from the National Institutes of Health (NIH), pain is the most common reason people seek medical care. We all have felt some type of pain. Let’s look to the Official Guidelines, as we always do when we experience confusion or want more information.

When Discharge Orders No Longer Signify Patient Discharge

As with many other physicians of a certain age, I have had the opportunity to practice patient care in both the worlds of paper and electronic charting.

Granted, as a pediatric hospitalist working in a busy, near-tertiary care center with little (purposeful) exposure to utilization management or clinical documentation integrity, my focus then on how...

What a medical coder looks for in an AI platform

Dawson Ballard, a coding auditor and educator for Chicago-based Rush University Medical Center who has more than 20 years experience in the profession, sees artificial intelligence coding platforms as beneficial. “It’s not foolproof, but it can certainly increase productivity,” he told Becker’s. Going the way of AI is a reality for health systems, but it is...

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