Instances of health care fraud account for billions of dollars of lost revenue a year throughout the industry. Without the correct safeguards installed to help identify and end fraudulent practices, health care providers could face investigations and penalties that could cost them significant amounts of revenue and threaten the financial health of their business.

That being said, creating relevant prevention policies and compliance plans to cover all facets of the laws governing fraud and abuse can often prove challenging for providers.

Complying with regulations at the local, state and national level can be difficult for providers who already focus on a range of priorities, including care delivery, payer compliance, medical billing, and revenue cycle management.

And at a time when payment rates are stagnating or dropping across payers, providers looking for every potential advantage to maximize revenue could conceivably engage in fraud and abuse crimes without intent.

Unfortunately, intent doesn’t factor in when the federal government comes to investigate these activities.

While CMS has made strides in recent years to be more proactive about educating providers engaging in potentially fraudulent activities, such as introducing its Targeted Probe and Educate (TPE) audit process, there still is a significant amount of gray area to operate in that can cause uncertainty and leave you vulnerable to takebacks down the road.

Providers will find CMS scrutinizing claim submissions more than ever to detect potential improper billing practices. In short, the days insurers simply paying then chasing are over!

What counts as fraud?

Fraud is defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit. Here are a few examples:

• Misrepresentation of the type or level of service provided;
• Misrepresentation of the individual rendering service;
• Billing for items and services that have not been rendered;
• Billing for services that have not been properly documented;
• Billing for items and services that are not medically necessary;
• Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);
• Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding).  Read More from Source