Healthcare Fraud Shield’s Latest Post: Let’s Explore Medicare Resources!

2 May

As an investigator, you can feel like you are constantly searching for laws, rules, and regulations to back up your case as well as information on how providers should be submitting claims properly. Where should you look to find your answers; the United States Code, Federal Register, Code of Federal Regulations, Medicare Benefit Policy Manual, Medicare Claims Processing Manual? There are so many places to look and some of the information in these sources is hard to read and confusing, am I right?

With all the resources out there on Medicare policies and benefits, one can get overwhelmed and confused on which to turn to. The Centers for Medicare & Medicaid Services (CMS) have created a “one-stop shop” where you can find fact sheets, booklets, web-based training courses, national provider calls, newsletters and more; all providing valuable information based on laws, rules, and regulations.

What is the Medicare Learning Network?

The Medicare Learning Network® (MLN) offers these educational resources to healthcare physicians, suppliers, and other fee-for-service (FFS) suppliers. Regardless, the information can benefit anyone who would like additional information on provider compliance, billing, coding, payment policies, and changes to CMS Programs. These resources are in easy-to-read and understand formats. Some of these formats also offer Continuing Education and Continuing Medical Education Credits. The online and downloadable products allow you to view products or save the information for later reference.

What to look for?

Let’s take a look at the Medicare Part B Immunization Billing fact sheet. This publication covers administration and diagnosis codes, vaccine codes and descriptors, as well as payment information and FAQs. If you’re looking into a provider who is billing vaccine codes and something looks out of the ordinary, this fact sheet is a great resource to verify which codes should be billed, how often they can be billed, as well as special billing information for different provider types. The information is laid out in an easy to read format and provides links to additional resources if you need to perform more investigation.

For example, Medicare typically covers one influenza vaccine per the influenza season.  Look for members who received more than one influenza vaccination for the season.  Remember to check your internal policies prior to making any determination. 

If you have questions or comments, reach out to one of our subject matter experts at

Join us for Healthcare Fraud Shield’s next Webinar: 

Quick Hits for Identifying Pharmacy and Medical Schemes on May 23rd, 2017 at 2:00 PM EST


Kenneth Cole, III, AHFI, CFE, CPC
Maria Seedorff, DC, AHFI, CPC
Kathleen Shaker, RN, BSN, CPC, CPC-H, AHFI
Karen Weintraub, MA, CPC-P, CPMA, AHFI
Click HERE to register!
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