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What Kinds of Billing and Coding Errors Constitute Health Care Fraud?

What Kinds of Billing and Coding Errors Constitute Health Care Fraud?

The importance of precision and care with medical billing cannot be understated. According to the False Claims Act, false medical coding and billing entries can be considered health care fraud. If you or your medical facility is facing health care fraud charges or an investigation because of coding or billing errors, it is important to work with an attorney. When you work with someone who understands applicable laws and has handled similar cases, you can have greater peace of mind that someone is handling matters on your behalf and working toward the most favorable outcome.

Since a reimbursement request that contains errors is considered a false claim under the FCA, it can trigger civil or criminal consequences. With civil liability, a party may face fines and other penalties. A mistake or accidental error does not eliminate liability since the FCA does not require intent for there to be a crime. However, if the Medicare Fraud Strike Force, the Department of Justice or another federal entity discovers intent behind medical billing or coding errors, criminal charges will likely be pursued. Penalties can include potential prison time and other harsh consequences for criminal convictions involving health care fraud. Attorneys work to have charges dropped or reduced to help clients try to avoid criminal charges.

Examples of Billing and Coding Errors That Constitute Fraud

It is important for all health care facilities to understand costly mistakes and how to avoid them. There are several types of coding and billing errors that can be considered fraud. These are some examples:

  • Intentionally or unintentionally using an outdated or incorrect billing code.
  • Billing for services that are not deemed medically necessary.
  • Coding or billing for a service that is costlier than the actual service that was provided.
  • Not complying with billing conditions for reimbursement.
  • Using modifiers inappropriately.
  • Double billing by billing the same agency twice, two insurers for the same service or multiple government programs for the same item or service.
  • Billing for services that require physician certification when a licensed physician is not available to certify them.
  • Billing for certain services individually when they should be bundled instead.
  • Attempting to bill for non-allowable expenses.
  • Billing for services that were provided by an excluded or unlicensed provider.

How To Address Medical Billing and Coding Error Risks

Individuals who handle billing for a small practice can limit risks by exercising care, learning all updated billing codes and checking work multiple times. Facilities can take several steps to minimize risks. Even with many protocols in place, it is possible for billing and coding errors to occur. When they become habitual, it is especially concerning. These are some tips to follow:

  • Train staff and regularly retrain them to learn new codes.
  • Develop a system to avoid duplicate billing.
  • Carefully align patient information with billing information.
  • Ensure that billing staff have the latest coding manual.
  • Verify benefits for patients in advance.
  • Hire a professional to conduct an audit of the billing and coding system.

Having a professional evaluate the system can be helpful to identify weaknesses and suggest improvements. It also helps to hire a professional medical biller or billing agency. Trying to have staff handle billing and coding, as well as keep up with current information, can be costly to many medical practices.

Medical Billing and Coding Error Defense Attorney

Are you being targeted for a federal investigation of medical billing and coding errors? If so, it is important to protect yourself or your medical establishment by hiring a federal defense attorney who understands the laws that apply to the False Claims Act and insurance billing. Investigations are serious matters, and any civil or criminal charges that may arise are also serious. We have helped other parties that faced health care fraud charges get through investigations and see favorable outcomes for their cases. To schedule a confidential consultation, please contact us.

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