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
- Modifier misuse, for example modifiers 25 and 59
- 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.
To learn more about EDI and become a certified EDI Professional, please visit our course schedule page.