According to CMS, there are several instances and situations based on which one can report healthcare fraud. CMS provides several ways “how to report a fraudulent medical billing practice.” CMS website contains phone numbers, online portals, fax numbers, and mailing addresses.
Following are the categories described by CMS:
For General Public & Providers – Report About Medicare & Medicaid.
Health & Human Services Office of the Inspector General
Health & Human Services Office of the Inspector General Website
Maximum of 10 pages
Office of Inspector General
ATTN: OIG HOTLINE OPERATIONS
P.O. Box 23489
Washington, DC 20026
If you think someone is stealing your identity, CMS will help you through Victimized Provider Project
For People with Medicare:
Medicare Parts A & B, C, D Information
- Medicare Parts A & B
Medicare Part C (Medicare Advantage)
Varies by plan
Refer to your plan’s general contact and/or fraud-reporting information
Medicare Part D (Medicare Drug Plan)
refer to your plan’s general contact and/or fraud-reporting information
For Parents or Guardians of Children with CHIP:
Check your state’s CHIP resources here. Afterward, look for reporting fraud on the relevant site.
For General Public – Report About the Health Insurance Marketplace
Fraudulent Billing Consequences:
Note that CMS violations can result in serious penalties for healthcare providers. With accurate information on federal penalties for healthcare fraud, medical providers can benefit from it by avoiding such practices. Several federal laws are in place for Medicare abuse and fraud.
Medicare Fraud and Abuse Laws:
These laws include:
- False Claims Act (FCA)
- Anti-Kickback Statute (AKS)
- Physician Self-Referral Law (Stark Law)
- Social Security Act, which includes the Exclusion Statute and the Civil Monetary Penalties Law (CMPL)
- The United States Criminal Code
As soon as you observe any fraud, you should report fraudulent medical billing to relevant authorities.
Examples of healthcare fraud in reference to the laws:
There are several examples of healthcare abuse and fraud; along with health insurance fraud punishments/penalties:
False Claims Act (FCA) involves:
- Healthcare providers knowingly submit claims to Medicare for the services not provided.
- Healthcare providers knowingly submit claims to Medicare for a higher level of medical services than the ones actually performed.
Penalties for violating FCA:
- For submitting false claims, “violating the civil FCA may include recovery of up to three times the amount of damages” sustained by the Government. It also includes financial penalties per false claim filed.
Anti-Kickback Statute (AKS):
- Receiving cash or medical office space rent that is below fair-market value in exchange for referrals.
- Criminal Penalties and administrative sanctions for violating the AKS may include:
- “fines, imprisonment, and exclusion from participation in the Federal health care program”
- Under the CMPL, penalties for violating the AKS may include three times the amount of the kickback.
Physician Self-Referral Law
- A physician refers a beneficiary for a designated health service to a clinic where the physician has an investment interest.
Penalties For Medical Billing Violations May Include:
- CMPs for each service
- Repayment of claims
- Potential exclusion from participation in the Federal healthcare programs.
Types of Medicare Abuse & Frauds:
There’s a significant difference between Medicare abuse and fraudulent practices. Medicare Abuse includes the practices that may “directly or indirectly result in unnecessary costs to the Medicare Program.”
However, Medicare fraud includes “knowingly submitting false claims to obtain Federal Health Care payment.” It also includes receiving or offering remunerations to induce or reward referrals for items or services reimbursed by Federal health care programs.
According to CMS (Centres for Medicare and Medicaid Services), several Medicaid frauds exist. Intentionally providing false information to Medicaid for getting paid for medical services or care provided is known as Medicaid fraud. Falsifying insurance eligibility is also an example of medical fraud. Following are some examples of health insurance fraud examples:
Examples Of Medicare Fraud And Abuse:
Using separate codes for reporting a medical procedure when a single comprehensive code exists is known as unbundling. There are a number of medical services that can be coded against one comprehensive CPT code. Using separate codes results in higher reimbursements from the insurance carriers. However, unbundling codes is an unethical practice and can result in civil liability for healthcare providers. Centers for Medicare and Medicaid Services (CMS) clearly state that unbundling and upcoding “can expose providers to criminal and civil liability.”
This practice is also considered Medicare abuse. It involves the healthcare provider submitting a medical claim by billing a more expensive or comprehensive medical procedure than the one performed. This act results in higher reimbursements. Upcoding also involves reporting more excessive time than the actual time spent on the procedure.
Examples of Medicare Fraud:
However, if providers bill for the following, it is categorized as Medicaid fraud.
- Knowingly billing for services of higher complexity
- Knowingly billing for services that were never performed
- Kickback schemes:
As stated by CMS, “Offering, soliciting, or paying for beneficiary referrals for medical services or items.” A kickback is when a healthcare provider offers payment to either encourage:
4. The patients come to their practice
5. Other healthcare practices or facilities to refer patients
This practice is unlawful to do so. As stated in the Medicare fraud and abuse booklet:
“Paying for referrals of Federal health care program beneficiaries” is Medicare fraud.
6. Services that were not provided:
Billing for the services, or procedures that were never performed is a common medical billing fraud. This also covers medical device fraud. It may include:
7. Billing Medicare for appointments or consultations patients fail to keep
8. Billing for devices that were not used or supplied
9. Multiple cards:
According to CMS, “intentionally and knowingly accepting multiple Medicaid ID cards from the beneficiary for reimbursements” is healthcare fraud.
Beneficiary examples for multiple cards include:
- Altering a Medicaid ID card
- Duplicating a Medicaid ID card
- Using the duplicated or altered Medicaid ID
- Selling the duplicated or altered Medicard ID for someone else to use.
10. Billing unnecessary medical services:
Procedures and medically necessary services are the ones that get reimbursed by Medicare and Medicaid services. Any medical services that have little to no role in diagnosing or treating your condition are considered medically unnecessary services. And if the healthcare provider or physician prescribes any of these knowingly, it is a violation of healthcare rules.
Tips for avoiding healthcare fraud:
Following are some tips for avoiding healthcare fraud.
Protect your healthcare insurance information:
Medicare ID should be used or given to the concerned parties only, i.e., healthcare providers or physicians. Take it as a credit card, don’t share sensitive information with anyone. Be mindful when someone asks for the information in order to offer you “free healthcare services.”
Be aware of the “free” services:
Note that if you’re asked for your Medicare information or social security number to offer you “free services,” there are chances they aren’t free. It is possible that it could be billed to your insurance provider fraudulently.
Check your EOB regularly – EOB stands for Explanation of Benefits:
Check and review the locations, dates, services, and procedures you are billed for, and match them with what you actually received. If you find anything alarming or concerns, contact your insurance provider.
Keep yourself updated with Medicare coverage rules and requirements.
Therefore, several services are not medically necessary and are not reimbursed by the insurance provider. This is why one should be very skeptical and aware of the services covered.
What to do if you think there’s a healthcare fraud-related problem?
Suppose you think your practice has engaged in any kind of healthcare fraud or abuse or any other problematic relationship. Following are some of the best practices to counter:
- Stop submitting problematic medical claims/bills immediately.
- Seek a proper and knowledgeable legal help
- Gather information regarding the wrongful or overpayments collected from the patients and federal healthcare programs. Report the issues and return these payments.
- If you think there is a suspicious relationship, free yourself from it.
- Consider using OIG’s or CMS’ self-disclosure protocols, as applicable.
Other unethical medical billing practices and errors include:
Under coding in medical billing includes not reporting codes of all the procedures performed. This can often happen due to oversight but can also be done intentionally by the providers. Under-coding in medical billing can result in patients being billed for lesser procedures or services performed. Therefore, it can result in a loss of revenue as physicians or providers are not reimbursed for all the services they perform.
Duplicate billing occurs when the same patient is billed for the same service or procedure multiple times when it was performed once. It can also be a result of human error.
Incorrect documentation and use of wrong codes:
Assigning valid and accurate codes depends on accurate and complete documentation. Sloppy or incorrect documentation by the physicians or healthcare providers makes it difficult to do correct medical coding. Missing information or misreading can lead to under-coding, which results in lost revenues for the healthcare practice.
Human error or incorrect documentation can also aid in the use of incorrect codes in medical claims. Even a minor mix-up in the code or wrong keystroke can change the code completely, resulting in the claim being denied.
Besides quality patient care, medical billing and coding are the two most crucial processes in the healthcare industry; for both physicians and patients. This process involves three parties;
- The healthcare provider/physician
- The patient
- The insurance payer
When it comes to billing a medical claim, accuracy is the key to avoiding claim denials, a lower reimbursement rate, and late payments. Errors in medical billing and coding directly impact the revenue cycle and reimbursements of the healthcare practice. Several medical billing errors are also considered “Medicare Abuse & Fraud” and can result in civil liability for the provider. These unethical practices may aim to either increase the revenues or lessen them to avoid audits. It can include provider billing for services or using codes of higher complexity (upcoding) and not billing all the services performed (under coding). Yes, these practices can also be due to a human error or mistake.
Frequently Asked Questions (FAQs)
1, How to report fraudulent medical billing?
According to CMS, there are several instances and situations based on which one can report healthcare fraud. Following are the categories described by CMS:
- For General Public & Providers – Report About Medicare & Medicaid:
- For People with Medicare:
- Medicare Parts A & B, C, D Information
- For Parents or Guardians of Children with CHIP:
- For General Public – Report About the Health Insurance Marketplace
2. How to report a medical clinic for fraudulent medical billing?
There are several ways provided by CMS how to report a fraudulent medical billing practice. CMS website contains phone numbers, online portals, fax numbers, and mailing addresses. It includes contact information for several categories like the general public, providers, parents, etc.
3. How to report fraudulent billing medical insurance medicare?
There are various federal penalties for healthcare fraud. With proper information on federal penalties for healthcare fraud, medical providers can benefit from it by avoiding the practices.
These laws include:
- False Claims Act (FCA)
- Anti-Kickback Statute (AKS)
- Physician Self-Referral Law (Stark Law), etc.
4. How to report fraudulent medical billing in Illinois?
Several medical billing errors are also considered “Medicare Abuse” and can result in civil liability for the healthcare provider. If you suspect any issues with your medical billing claim, refer to the insurance department. You can also contact Medicare via the contact information provided by them. Remember, it is important to report fraudulent medical billing
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