The Compliance Program Guidance was issued to assist physicians in developing compliance programs for their practices and prevent fraud and abuse against government health care programs.  According to this article, fraud and abuse can include:

  • Billing for services, procedures and/or supplies that were not provided.
  • Misrepresentation of what was provided; when it was provided; the condition or diagnosis; the charges involved; and/or the identity of the provider recipient.
  • Providing unnecessary services or ordering unnecessary tests.
  • Unbundling of claims: billing separately for procedures that normally are covered by a single fee
  • Double billing: charging more than once for the same service.
  • Upcoding: charging for a more complex service than was performed. This usually involves billing for longer or more complex office visits (for example, charging for a comprehensive visit when the patient was seen only briefly), but it also can involve charging for a more complex procedure than was performed or for more expensive equipment than was delivered. Medicare documentation guidelines describe what the various levels of service should involve.
  • Miscoding: using a code number that does not apply to the procedure.
  • Kickbacks: receiving payment or other benefit for making a referral.
  • Unnecessary X-rays/tests.
  • Many insurance policies cover a percentage of the physician’s “usual” fee. Some physicians charge insured patients more than uninsured ones but represent to the insurance companies that the higher fee is the usual one. This practice is illegal.
  • Waiving co-payments and deductibles. (A co-payment is a fixed dollar amount paid whenever an insured person receives specified health care services. A deductible is the amount that must be paid before the insurance company starts paying.) It is legal to waive a fee for people with a genuine financial hardship, but it is not legal to provide completely free care or discounts to all patients or to collect only from those who have insurance.

To help prevent these practices from occurring, the OIG has outlined seven steps for physicians and group practices.  Click here to read the seven steps and the entire article.