7 Most Common Health Care Billing Abuses

At a recent Health Care Fraud Prevention and Enforcement Action Team presentation given by the Office of Inspector General (OIG), the agency stressed the importance of documentation and identified the following seven common billing abuses performed by providers.  These are:

  1. upcoding – billing a code for a more expensive service than the one actually provided
  2. unbundling – billing separately for services that are properly grouped  within a global fee (e.g., global surgery fee – surgery, and then for follow up visit)
  3. lack of medical necessity – billing for medically unnecessary services  (e.g., ordering a wheelchair for one who does not need)
  4. billing for services not rendered – billing for services that were not provided
  5. worthless services – billing for services that are of such low quality that they are worthless
  6. duplicate billing – billing twice or more for the same service
  7. lack of documentation – billing when the medical record cannot back up the claim

Furthermore, billing for services that were performed by an employee who has been excluded from participation in the Federal health care programs would also be considered improper.

OIG stressed that proper documentation is essential not only for program integrity, but also for patient safety as well as to protect the provider.  Healthcare providers should be aware that the OIG takes the position that if you did not document it, it did not happen.  Furthermore, OIG also went on record to state that going forward there is an increased enforcement of documentation requirements.

The delivery of healthcare services in the 21st century means not only delivering professional healthcare services but also wading through the myriad of regulations imposed by federal, state and local authorities.  If you performed healthcare services, protect yourself by properly — and legibly — documenting your services.