Medical coding fraud can be committed knowingly or unknowingly. To make matters worse, the coding rules are constantly changing. The submission of incorrect coding and billing information usually results in heavy penalties and legal action, and worse, loss of reputation. In a recent case, a service provider ended up paying over $4 million to settle alleged violations of federal and state regulations due to the submission of various incorrect and fraudulent claims to government health programs including Medicare.
Some common examples of medical coding fraud:
Double billing: If a procedure was only performed once, but the single billing code is submitted multiple times, this is considered double billing.
Upcoding: This involves coding a higher or more complex level of service than was actually rendered. This would mean the submission of a higher reimbursement rate than actually necessary. For example, in radiology coding, while interpreting lumbar spine radiographs obtained in a patient, the exact listing in the CPT manual has to found. If the exact listing is not available, the closest match must be sought. Otherwise, the claim could end up as abuse or fraud.
Downcoding: It assigns the patient a lesser diagnosis and sometimes showing fake patient improvement.
Unbundling: Manipulating the CPT codes to increase reimbursement is considered a distortion of the services rendered.
Incorrect codes: Assigning incorrect codes is a misrepresentation of services rendered and also considered fraudulent.
Medical billing and coding fraud can be avoided if the job is handled by expert certified (AAPC) coders who are up-to-date with all the developments in the field.
Fraudulent Medical Coding Penalties
Under the government’s 1986 False Claims Act (FCA), those charged with medical fraud could be fined a whopping amount of $5,500 to $11,000 per claim. The best way to avoid fraud is to get your medical billing and coding handled by a professional medical billing and coding company. This will save time and money.
Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.