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4 actions that can lead to Medicare fraud

On Behalf of | Jan 10, 2024 | Medicare Fraud |

Medicare fraud is a serious offense that can have severe consequences for those involved.

Even well-meaning medical professionals may find themselves unintentionally breaking the law.

1. Unbundling services

One common pitfall is the unintentional practice of unbundling services. This occurs when a medical professional bills Medicare services individually instead of together. For instance, if a doctor performs a comprehensive examination and orders laboratory tests, these services should result in a single package bill. Unbundling them may lead to allegations of fraud. In FY 2023, improper Medicare Fee-for-Service payments reached $31.2 billion.

2. Upcoding

Another unintentional mistake is upcoding, where a medical professional assigns a higher billing code to a service than what was actually provided. This can happen due to errors in documentation or a lack of clarity in coding guidelines. For example, a routine office visit may have a higher bill level if the documentation does not accurately reflect the complexity of the encounter.

3. Lack of medical necessity

Submitting claims for services that are not medically necessary is another potential pitfall. Medical professionals may unintentionally order unnecessary tests or procedures, leading to accusations of fraud. This could result from a misunderstanding of Medicare’s guidelines or pressure to generate revenue for a medical practice.

4. False certification

Certifying false information on Medicare documents is a serious offense. Medical professionals might inadvertently sign off on inaccurate information or documentation due to oversight or miscommunication within the healthcare team. This can lead to allegations of fraud, even if the intention was not malicious.

Understanding the common pitfalls and taking proactive steps to ensure compliance with Medicare regulations can significantly reduce the risk of unintentional fraud.