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Overbilling could lead to charges for health care fraud

by | Mar 9, 2018 | Blog |

More than likely, you would rather focus on your practice as a physician than worry about the management of your practice. You employ others to handle those tasks for you. However, if you fail to oversee on your billing, you could find yourself under investigation or even arrested for health care fraud.

Like most other doctors, you probably accept Medicaid and Medicare. Under the watchful eye of the Centers for Medicare & Medicaid Services, you need to make sure that nothing in your billing may appear fraudulent.


As you know, every service a doctor provides has a corresponding billing code. When a physician uses “up-coding,” he or she is charging for a more expensive service than the one that was actually performed. For instance, a doctor may charge for the most expensive office visit when the patient’s records don’t support the use of that code. If the care, diagnosis and treatment plan do not fit with a certain billing code, it constitutes overbilling, which is fraud.

Attempting to point the finger at your biller won’t work. The buck, as they say, stops with you. If you fail to oversee the work done by the person handling your billing, you could end up in trouble. You could face criminal charges and jeopardize your license.

What to do

In order to avoid potential fraud charges, you may want to familiarize yourself with your billing codes and how they relate to the services you provide. In addition, it may help to compare your billing practices to those of others in your specialty. Any deviations from what others consider normal could bring you to the attention of CMS and others in the government.

On the other hand, you could discover that you are losing money because of underbilling. In either case, you may need to fix some issues with your billing. If numbers and paperwork aren’t your thing, you could hire someone to perform a billing audit to not only search for any potential overbilling or underbilling, but also to help you maximize your billing. If you tend to cut and paste information from one patient’s record to another, new software could pick up on that and flag your billing.

More than likely, you did not intend to defraud anyone. Instead, if you are guilty of anything, it’s relying too much on someone else or technology. You may be busy and simply want to spend more time with your patients than your paperwork. However, doing so could cause you problems. In fact, if you find yourself under investigation for health care fraud, taking immediate action could help save your license, your career and your record.