Medical Billing Fraud

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. 1). 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.

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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 both personally and with dated, written memorandum. Document the false statement or representation of the material fact. Send a memorandum to the office manager or employer stating your concerns if no change are made. Maintain a written audit trail with dated memoranda for your files.

Don’t discuss the problem with anyone who is not immediately involved (pg. 43). Honesty and Integrity are key elements to a good medical biller. So in order for us to get rid of medical billing fraud we need to practice timely, accurate and complete documentation. If you have any questions on the codes you are being asked to code for the insurance companies, please ask the physician to make sure all is correct. Link the appropriate diagnosis with the appropriate procedure code. Make sure to use the appropriate modifiers.

Identify all other insurance coverage when billing so there isn’t any double billing. Mainly double check and ask questions if you have them. Many fraudulent medical claims can be detected by examining insurance payment reports to see if they are accurate with the services that were rendered. A medical coding specialist has an ethical obligation to submit accurate claims for services provided. A thorough understanding of the contracts and rules, in preparing claims, prevents fraudulent submission of claims. There are times when an organization will request, or encourage, a dishonest billing practice.

According to AHIMA Standards of Ethical Coding, ‘coding professionals should refuse to participate in or hide unethical coding practices or procedures. The standards instruct coding professionals to act ethically at all times. The coding professionals are not to hide or excuse any unethical practices in an attempt to avoid the standards established by the industry. It is the responsibility of all individuals to notify the insurance carrier of any suspicious situation.


  1. www. all-things-medical-billing. com/what-is-medical-billing-fraud. html

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Medical Billing Fraud. (2016, Sep 23). Retrieved from