Most Texas healthcare providers dedicate themselves to improving the lives of the patients they serve and providing quality, honest care. There are a small number of doctors and providers, however, who use fraudulent billing practices to generate more income. Others may not be careful enough with their medical coding and billing and abuse the system unknowingly.

What is fraud, and what coding mistakes do medical providers need to avoid to steer clear of it?

Medical fraud definition

Johns Hopkins HealthCare defines medical fraud as any act that benefits an unauthorized person and is committed deliberate and dishonest. Egregious coding mistakes or poorly monitored business practices can be medical abuse. Both fraud and abuse are criminally and civilly actionable.

Coding mistakes to avoid

According to the American Medical Association, here are some common coding mistakes.

  • Upcoding – This happens when a provider codes a service as something longer or more complicated than it was. For example, if a provider meets a patient for a few minutes for a medication check but bills it as a 45 minute exam.
  • Unbundling – Sometimes a single code will cover multiple parts of a procedure. “Unbundling” is billing each of these separately and can be a dishonest practice.
  • Not checking National Correct Coding Initiative edits – If reporting multiple codes for the same patient during the same visit, it is important to check the NCCI edits for proper reporting.
  • Failing to properly document the use of modifier 22 – When using modifier 22, a provider must show proper documentation detailing why the procedure was more difficult or required more work.

Medical providers should diligently monitor their coding and billing practices to avoid the semblance of fraud or abuse.