Occasional innocent billing errors are not the same as Medicare fraud or False claims act violations. Billing compliance audits can find these errors and when promptly corrected the entity can avoid CMS and OIG penalties, absent a violation of law.
Typical examples of fraudulent activities under FCA, AKS, Stark laws:
1. Billing for services, procedures and supplies not provided;
2. Misrepresenting services provided; what, when, who (MD, PA, NP), why (condition or diagnosis), or how much (charges).
3. Providing unnecessary services or ordering unnecessary tests (documentation of need/reasoning);
4. “Unbundling of claims” billing separately for procedures that normally are covered by a single fee;
5. Double billing: charging more than once for the same service;
6. Up-coding: charging for a more complex service than was performed;
7. Mis-coding: using a code number that does not apply to the procedure;
8. Kickbacks: receiving payment or another benefit for making a referral;
9. Performing unnecessary X-rays and lab tests (similar to #2 but these were provided unnecessarily);
10. Charging insured and uninsured patients differently (absent insurance contract); and
11. Waiving co-payments and deductibles.
To discourage and avoid common fraudulent activities:
1. Conduct internal monitoring and auditing (risk and compliance);
2. Implement compliance and practice standards;
3. Designate a compliance officer;
4. Training and education;
5. Develop a corrective action for detected errors;
6. Foster open communication with employees;
7. Enforce disciplinary standards through well-publicized guidelines.