{"id":15476,"date":"2022-06-14T11:06:27","date_gmt":"2022-06-14T11:06:27","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=15476"},"modified":"2026-05-11T14:49:42","modified_gmt":"2026-05-11T14:49:42","slug":"avoiding-fraudulent-billing-as-a-new-medical-practice","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/avoiding-fraudulent-billing-as-a-new-medical-practice\/","title":{"rendered":"Avoiding Fraudulent Billing as a New Medical Practice"},"content":{"rendered":"

As a healthcare provider, during your residency, you probably are not focused on who pays for your patients\u2019 care. Once you start practicing, it is important to understand who the payers are. The U.S. healthcare system relies heavily on third-party payers, and, therefore, your patients often are not the ones who pay most of their medical bills. <\/span><\/p>\n

Third-party payers include commercial insurers and the Federal and State governments. When the Federal Government covers items or services rendered to Medicare and Medicaid beneficiaries, the Federal fraud and abuse laws apply. Many States also have adopted similar laws that apply to your provision of care under State-financed programs and to private-pay patients. <\/span><\/p>\n

Consequently, you should recognize that the issues discussed here may apply to your care of all insured patients. The topics discussed in this article will help you in avoiding fraudulent billing as you have just started your new medical practice.\u00a0<\/span><\/p>\n

Accurate Coding and Billing<\/span><\/h2>\n

Government and even commercial payers trust you, as a physician, to provide necessary, cost-effective, and quality care. You exert significant influence over what services your patients receive, you control the documentation describing what services they actually received, and your documentation serves as the basis for bills sent to insurers for services you provided. <\/span><\/p>\n

The Government\u2019s payment of claims is generally based solely on your representations in the claims documents.\u00a0<\/span>Because the Government invests so much trust in physicians on the front end, Congress provided powerful criminal, civil, and administrative enforcement tools for instances when unscrupulous providers abuse that trust. <\/span><\/p>\n

The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients.<\/span><\/p>\n

Let\u2019s consider an example of billing Medicare or Medicaid. When you submit a claim for services performed for a Medicare or Medicaid beneficiary, you are filing a bill with the Federal Government and certifying that you have earned the payment requested and complied with the billing requirements. <\/span><\/p>\n

If you knew or should have known that the submitted claim was false, then the attempt to collect unearned money constitutes a violation. A common type of false claim is \u201cupcoding,\u201d which refers to using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided. <\/span><\/p>\n

Additional examples of improper claims include:<\/span><\/h3>\n