NOC Claims, OIG Excluded Providers, and Combat Fraud Perception


NOC Claims and Ensuring Your Practice is Reimbursed

When there is a new drug or procedure that comes to market, it typically takes the Centers for Medicare & Medicaid Services (CMS) about six months to evaluate it and determine a reimbursement rate. During that time period (sometimes up to a year), practices can start billing under a Not Otherwise Classified (NOC), Unspecified or Miscellaneous Code.

Many practices wait until a specific J-code is assigned, but CMS has issued J-codes for those NOC, unspecified drugs for independent practices.

  • J3490 – unclassified drugs
  • J3590 – unclassified biologics
  • J9999 – not otherwise classified, antineoplastic drugs

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Understanding Your Practice’s Responsibility with OIG Excluded Providers

As healthcare costs continue to increase, the Centers for Medicare & Medicaid Services (CMS) has employed more agencies to conduct investigations to find improper payments through either fraud, waste or abuse. In a semiannual report to Congress released in November 2017, CMS noted that $4.13 billion in investigative recoveries were made. In addition to the monies recouped, 3,244 individuals and entities were banned from participating in federal healthcare programs going forward.

With that high of a return and an anticipated recovery of nearly $3 billion in 2018, CMS wants to continue to look to recoup funds. CMS will report their findings twice a year to Congress.

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Addressing Your Office Procedures to Combat the Perception of Fraud

The Fraud Prevention System (FPS), implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011, uses models that predict suspicious behavior with the goal of preventing the payment of fraudulent claims. This system has saved the federal government millions of dollars. For example, in fiscal year 2016, CMS reported that 90 providers had their payments suspended because of investigations initiated or supported by FPS, which resulted in an estimated $6.7 million in savings.

The FPS analyzes claims to identify health care providers with suspect billing patterns. While some of those payments are related to potential fraud, others may be highlighted from simple in-office mistakes – like misidentifying the place where service was rendered. Those mistakes may be highlighted as potential fraud and spur government contractors to triage the leads faster – taking valuable administration time from you to refute the investigation.

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