Improper or sloppy billing practices can lead to accusations of health care fraud. As a physician, you should be diligent in compliance and accuracy. Avoid accusations of fraud by understanding common improper procedures and following steps to make your billing and coding processes more coordinated.
1. Services not provided
A billed item or service must have been provided to the beneficiary. Some physicians bill services without providing them. For example, a physician may forge a signature of a beneficiary and fill out time sheets of care that was not provided. Make sure the service in question is provided before billing.
2. Services not necessary
Only services that are in your state plan are authorized for beneficiaries. Not only must your billed services be authorized, but they must also be medically necessary. As a physician, you are responsible for ensuring your services meet the standard of medical necessity. Signing a billing document means you are certifying the claims are authorized, necessary, accurate and complete.
Another common type of improper billing practices is billing for services that are far more complex than what was provided. For example, a physician may bill for a 30-minute session when it was only 10 minutes long. Another example is providing patients with cheaper and unapproved medications but billing for more expensive and approved medications.
4. Services not covered
Another type of health care fraud to avoid is billing services that are not covered by the provider in question. Coverage relies on various frequencies and complexities. A patient may be provided with a service that is medically necessary, but falsifying diagnoses or providing certain services too frequently is fraudulent behavior.
Unbundling occurs when a health care provider submits fragmented bills to maximize reimbursement. Certain procedures or tests must be billed together and separating them can lead to the health care provider getting higher reimbursements. Manipulating codes and billing separate codes is health care fraud and must be avoided.
Avoiding committing health care fraud is best prevented by following guidelines for accurately coding and billing your services. Fraud may even be committed unintentionally so it is crucial to be aware of fraudulent practices and avoid them at all costs. Unintentional fraud or false accusations of fraud can be devastating for physicians and other health care providers. If you are being accused or investigated for health care fraud, know your legal rights. Seeking counsel from a criminal defense attorney will give you the representation you need.