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Billing and Coding Errors

Unintentional coding and billing errors are among the most common issues that can trigger health care fraud investigations. Providers that participate in Medicare, Medicaid, Medi-Cal and other government health care benefit programs are subject to an extraordinarily complex regulatory scheme that includes includes numerous specific requirements - some of which contradict other requirements for obtaining reimbursements for services, supplies, durable medical goods, and medications. These regulatory schemes and their requirements are constantly changing and maintaining compliance with the applicable billing requirements is a challenge that requires deep health care law knowledge and constant dedication to maintaining compliance.

Unfortunately, mistakes are made. Billing and coding errors are very common. And when they trigger the federal health care authorities’ monitoring systems, they can lead to costly investigations. Evidence of knowledge or intent is required to establish criminal culpability for most fraud cases but even simple administrative errors and honest mistakes can lead to federal civil cases with fines of more than $20,000 per “false claim”. And that doesn’t include recoupment, other financial penalties, or loss of eligibility.

Billing errors may include:

  • Double-billing a health care benefit program.
  • Billing the government and private insurer for the same product or service.
  • Up-coding or billing at a higher rate than prescribed by reimbursement regulations.
  • Billing for costs or services that are otherwise ineligible for reimbursement, including services provided by unlicensed or excluded services that are medically unnecessary.