We have developed two new reason codes that flag providers who appear on government watchlists and are excluded from participation in government-sponsored programs such as Medicare and Medicaid.
Medicaid and Medicare fraud result in nearly $100 billion in losses annually. This potentially includes activities such as billing for unprovided services and conducting unnecessary procedures. Some providers engage in various wasteful and fraudulent practices to exploit government programs intended to assist the most vulnerable populations. The Office of Inspector General (OIG) is a government agency dedicated to combating fraud, waste, and abuse within the provider sector, particularly concerning this potential exploitation of Medicaid and Medicare. They maintain a watchlist of providers barred from participating in government programs due to ongoing investigations into their practices. These reason codes integrate this data into the Provider Scoring solution, flagging any provider listed.
With these new upgrades on intelligence, investigators now have visibility into potentially suspicious providers who may require additional investigation into their billing practices due to their presence on government watchlists. Customers can leverage these new reason codes in Provider Scoring Insights, the Providers Page and Provider Scorecard.
