What Is Medical Insurance Billing and Coding Fraud?

What Is Medical Insurance Billing and Coding Fraud?

Ambulatory Surgery Center BillingPayers who are billed for medical expenses look at such invoices with skepticism. In a recent report, the FBI noted that medical fraud, including that related to physician and patient efforts, was responsible for costing insurers $3 trillion in 2014. Thus, it makes sense that agencies and insurance companies that must reimburse individuals and practices for medical costs and billing would be on the lookout for potential fraud.

One of the charges that medical billing and coders are given is to report any suspicions that they have of fraud. Law enforcement understands that because we are intimately involved in the process, we often have access to and knowledge of individual practices and their billing methods.

How Medical Insurance Billing Fraud Works

Medical insurance billing fraud occurs when someone purposely and knowingly files false, inflated, and/or inaccurate claims with insurers. This is done in an attempt to collected payments to which the filing party is not entitled.

Although many such claims are made by individuals not in the medical field, the FBI notes that there is growing fraudulent practices amongst healthcare providers, which means that in the eyes of insurers every healthcare professional is a potential fraudster.

The Most Common Kind of Fraud

The most recognized type of fraud perpetuated by medical providers involves a healthcare professional submitting a claim for more work than they have actually done. Such charges are often added onto a bill that is, otherwise, accurate. Along with being illegal, medical insurance fraud costs insurance companies, the government, and law enforcement a lot of time, effort, and money.


Methods used to bill insurance companies out of money include:

• Ordering unnecessary procedures or tests
• Billing for services not provided
• Changing or upgrading services provided
• Separating procedures performed at the same time and billing for additional visits
• Double billing for the same procedure

Fraud Does not Involve Mistakes

There are times when healthcare providers make mistakes in billing. Such practices are occasional and recognized as such. Fraud tends to be habitual and done in a manner that creates certain billing patterns. Medical billing and coding companies have a responsibility to be vigilant concerning fraud. It’s important that healthcare providers submit their medical billing claims and invoices in a complete and accurate manner.

How We Can Help

The professional medical billers and coders at Medical Practice Management Resources, Inc., can help to ensure that all medical claims submitted to insurers are compliant and trustworthy. In addition, we are charged with making sure that insurers respond in an appropriate fashion, and that your claims are processed honestly and fairly.

Our personnel are focused on keeping the conduit of communication open on all levels, which means if we have a question concerning a bill, we will contact you to make sure all information is accurate and correct. In dealing with insurance providers, we will double check all responses, decisions, and payments, and follow up when we perceive any problems.

In this way, the staff at Medical Practice Management Resources, Inc., works to validate the entire process of medical billing and coding, ultimately saving you money by enabling timely payments from insurers.

MPMR offers the best medical billing and revenue management services nationwide for many specialties including ambulatory surgery centers as well. Call us today!


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