Fraud

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Billing and Coding Fraud
Michael Anastasio
Ultimate Medical Academy

Before answering the questions “what are my responsibilities for billing on a procedure that was not performed but asked to do so anyway”, Let me explain a little on Medical Billing Fraud? It is an attempt to fraudulently obtain payments from insurance carriers. Fraud in medical billing cost tax payers and medical providers millions of dollars annually (all-things-medical-billing.com). In 1996, HIPPA established the Health Care Fraud and Abuse Control Program (HCFAC) to help combat medical billing and health care fraud (pg.41). Fraud is an act done with the knowledge that you are doing wrong. Fraud is the intentional deception and misrepresentation that is to result in an unauthorized benefit. Abuse is the charging of services that are not medically necessary. False claim schemes are the most common type of health insurance fraud. The reasoning to do fraud is to obtain undeserved payments for claims. Some schemes to watch out for are: Billing for services, procedures and/or supplies that were not used. Unbundling of claims, this is billing separately for procedures that are covered by a single fee. Double billing, this is charging more than once for the same service.Upcoding, this is charging for more complex services than was performed. As a medical biller my responsibilities for procedures that were not preformed but asked to bill for would to be proactive in preventing fraud and it can be done by creating a uniform checklist(pg.46) to follow whenever a claim is submitted. It is also a good rule of thumb to have one person submitting claims and have another posting payments, adjustments and credits. You could also have one person filling out the claim and another person double checking the claim before submitting the claim, or posting payments and adjustments. As coder or biller, and having knowledge of fraud or abuse, taking the following measures should be done. Notify the provider...
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