Medicare Could Auto-Deny 100 Percent Of Suspicious Claims

Medicare's Program Safeguard Contractors (PSCs) will be on the lookout for "high-risk areas" soon.

These are groups of claims with unusual patterns that show a potential for fraud and abuse. Warning signs could include:

Another big warning sign would be a doctor ordering outside services for a patient when the ordering doctor has never seen the patient. Doctors shouldn't order services for a patient unless they've already billed for their own services provided to that patient.

When they find a high-risk area, the PSCs can impose their own edits on claims, including prepayment medical-review edits. They can also impose automatic denials on 100 percent of a provider's claims, send Medicare Summary Notices more often, check a provider's enrollment status and work with beneficiaries more closely, according to CMS Transmittal 210 (CR 5626).