Eligible for: ACMPE: 1|ACHE: 1|CEU: 1|CME(AAPC*): 1|CPE: 1.2|PDC: 1 Traditional | Intermediate | Analysis * This session is included in the 2025 MGMA Summit education program.
Margins are tight, and enforcement agencies continue to scrutinize claims and reimbursement. This session will focus on current trends in revenue cycle enforcement cases and the financial risks of commonly scrutinized types of services. Through a case study approach, we will review actual cases of revenue cycle activities gone awry that resulted in financial fines and/or settlements. The session will explore lack of medical necessity, with sample cases involving urine drug testing, radiology and images services, interventional vascular procedures and pain management; E/M services, with sample cases on upcoding and lack of documentation; misuse of coding modifiers, with sample cases on modifiers -25 and –59; and in appropriate use of incident to billing.
Learning Objectives:
Examine the current trends in revenue cycle scrutiny and enforcement
Breakdown the financial, legal and reputational consequences of revenue cycle noncompliance through case study examples
Organize strategies and tools that can help healthcare organizations avoid revenue cycle non-compliance
