Physician's Coding Strategist-OIG to review claims software

Problems with proprietary software

Although Medicare claims software written for commercial distribution to a large audience poses little risk of producing erroneous or false claims, proprietary software appears more likely to pose some risk of misuse or fraudulent use, according to a report released by the Office of the Inspector General (OIG) in Washington, DC.

The OIG had decided to review software literature and claim preparation processes because of the vast numbers of claims that were being electronically submitted to Medicare.

Here's what the report found

The report, "Medical Billing Software and Processes Used to Prepare Claims," found many potential problems with the submission of the claims, including:

• Medicare cannot identify most of the clearinghouses and billing agencies submitting claims into the Medicare systems because most use the physician's or medical supplier's billing number and submitter number.

• Medicare can't determine whether claims enter its system from an authorized biller's site and computer or from unauthorized sites and computers.

• Billing companies, their employees, and employees of providers have access to patient and provider information needed to gain entry into the Medicare system.

The Health Care Financing Administration in Baltimore has taken a "step in the right direction" by creating a new computer system, called the Provider Enrollment, Chain and Ownership System. The OIG made these further recommendations in its report:

• Identify and register all clearinghouses and third-party billers. This would provide an audit trail.

• Improve safeguards to ensure that electronic claims are accepted only from authorized sites and terminals.

• Educate the provider community about its liability for erroneous claims submitted to Medicare using its provider number(s).