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Billing and Coding Investigations and Self-Disclosure

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BRG experts have worked on several matters involving internal or external investigations into provider billing practices to commercial and government-sponsored programs. BRG’s engagement tasks on these matters have generally included isolating the population of relevant billings through analysis of historic paid claims data and then using that information to design a statistical sampling plan, perform a detailed coding/medical records review, and conduct a statistical extrapolation to determine the value of overpayments, if any, received by the provider.

In conjunction with some of these investigations, our experts have also assisted counsel in drafting self-disclosures to the Centers for Medicare and Medicaid Services (CMS). Some of the alleged inappropriate billing practices BRG experts have investigated include, but are not limited to, the following:

  • DRG creep and CPT upcoding
  • Inappropriate hospital admissions and short lengths of stay
  • Exaggerated diagnoses (over-reporting of complications and comorbidities)
  • Provision of and billing for medically unnecessary services
  • Duplicate billing and billing for services not rendered
  • Non-compliance with Medicare and Medicaid coverage determinations
  • Insufficient documentation of services

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