HIPAA training

Fraud, Waste and Abuse (Louisiana Healthcare Connections)

Some of the most common coding and billing issues are:

  • Billing for services not rendered
  • Billing for services at a frequency that indicates the provider is an outlier as compared with their peers.
  • Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
  • Billing for services that are actually performed by another provider
  • Up-coding
  • Modifier misuse, for example modifiers 25 and 59
  • Unbundling
  • Billing for more units than rendered
  • Lack of documentation in the records to support the services billed
  • Services performed by an unlicensed provider but billed under a licensed providers name
  • Alteration of records to get services covered
  • Member Fraud and Abuse:
    • Obtaining unnecessary medications or products and selling them
    • Providing false information to apply or qualify for services
    • “Doctor shopping” to get multiple prescriptions
    • Using someone else’s insurance, or allowing someone else to use your own, coverage to receive services
    • Forging or altering receipts
    • Filing claims for services not rendered or products not received.

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