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Classifying improper payments: Mistake, abuse or fraud?

On Behalf of | Jul 1, 2020 | Medicare / Medicaid Fraud

Although it’s not possible to determine the exact cost of Medicare abuse, the exploitation of Federal healthcare is a serious issue in the United States. Together, Medicare fraud and abuse cost taxpayers billions of dollars and limit the effectiveness of the programs meant to serve Americans in need of them.

These programs rely heavily on the ethical support of physicians and healthcare providers. Much of healthcare fraud and abuse occurs in the billing stage.

What is the range of improper billing practices?

The circumstances, intent and knowledge of the healthcare professional matters in determining whether an instance qualifies as a mistake, fraud or abuse.

Here are some general examples of the different categories of improper payments:

  • Mistakes which result in billing errors, such as incorrect coding
  • Inefficiencies which result in waste, such as ordering unnecessary testing or too much equipment
  • Bending the rules, resulting in abuse, such as improper billing practices like upcoding
  • Intentional deceptions, resulting in fraud, such as billing for services or supplies that were not provided to the patient

These examples are meant to provide a general idea but are not definitive. Depending on the surrounding circumstances, actions described in any category could be subject to administrative, civil or criminal penalties.

Reporting improper Medicare billing practices

If you work in the billing office of a healthcare facility and notice worrying discrepancies, you can report suspected fraud or abuse to the Office of Inspector General. There are various hotline options, and you can even pass on an anonymous tip if you are not comfortable giving your name.