Dangers of Erroneous Submission of Medicare Claims

by | Published on Aug 7, 2013 | Healthcare News

Medicare Claims
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The faulty submission of medical claims can get you into serious financial trouble and adversely impact the bottom line of your practice. A recent example is the case of the St Luke’s University Health Network which faced allegations that it erroneously submitted improper claims to the Medicare program.

The contention was that during the period January 1, 2002 to June 30, 2012, St. Luke’s University Health Network made erroneous claim submissions to the Medicare program for reimbursement of evaluation and management services that were not permitted under Medicare. The government established that the St Luke’s group of hospitals incorrectly attached Modifier 25 to Medicare claims for services that were not significant and separately identifiable from the usual preoperative and postoperative care associated with the procedure. St Luke’s fully cooperated with the government’s investigation, but paid up to $1,029,791 to resolve the issue.

It is your right to claim reimbursements for the patient care services you performed. However, the government expects you to submit accurate Medicare claims. Medicare fraud is a very serious issue. To avoid committing what is termed ‘fraud’, take care to avoid the following:

  • Submit bills for services not provided, or services that were not necessary.
  • Upcode a service: This happens when you charge Medicare for a more expensive service than was provided. For instance, billing for surgery when the service provided involved just placing a bandage over a cut.
  • Unbundle services: If separate bills are submitted for lab services comprising three or four tests, which are supposed to be billed as one service.
  • Bill non-covered services as covered services.

CMS has added on new provider enrollment provisions in 2013 to enhance the integrity of the Medicare program and prevent fraud. According to the new provisions, Medicare can revoke your billing privileges if your practice has a pattern of billing for services that do not meet Medicare guidelines. The best way to avoid these issues is to opt for the professional medical billing and coding services offered by an experienced medical billing company. With an expert team of billing specialists and AAPC-certified coders, a reliable service provider can help you avoid inadvertently submitting incorrect Medicare claims.

Natalie Tornese

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.

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