ICD-10 and the fraud problem

No one likes fraud and abuse. That's what led to the Centers for Medicare & Medicaid Services (CMS) fraud prevention system (FPS). It uses ICD data to identify patterns that could identify fraud.

Except on Oct. 1, the data FPS uses is going to be based upon ICD-10 coding. Unless CMS has a massive dual coding effort, it's not going to be able to match ICD-9 patterns with ICD-10 data.

They will figure it out eventually. But there's going to be a time that very legitimate claims will be flagged as possible fraud.

Here's the big problem:

"CMS is abandoning the 'pay and chase' paradigm of fraud, waste, and abuse remediation," according to a Bloomberg Law article on ICD-10 preparation. That means that the federal government isn't automatically paying medical claims and demanding the money back if they determine there was fraud. Medical practices will not be presumed innocent if their medical claims are flagged as possible fraud. They will need to substantiate claims quickly to get reimbursements.

And documentation will be key. Medical practices must be ready to show their diagnoses are legitimate.