Illegal Billing Practices

Illegal Billing Practices

Illegal billing practices such as upcoding, churning, and unbundling are a challenge experienced by Medicaid and Medicare (Chen et al., 2022). A physician committed fraud by billing for services he delivered, including a laboratory test performed by an unsupervised trainee student. The particular test conducted was unnecessary to determine the patient’s diagnosis, and payment for such a test is included in a global fee. The physician was fined for three fraudulent billing practices: billing for a service conducted by an unqualified person without supervision, billing separately for a test clearly outlined as part of a global fee and billing for unnecessary service. The physician admitted to his crimes and pled guilty to all three counts of fraud. He was fined $900,000 and sentenced to three years of probation.

Actions are taken against providers who engage in illegal billing practices to prevent the occurrence of more cases (Chen et al., 2022 ). A provider can be excluded from participating in insurance delivery and not having records to support claims. The fraudulent bill can be processed but withheld or not paid. The provider is prosecuted for his crimes; when found guilty, they are fined, jailed, or both. Depending on the illegal billing, a provider’s contract is suspended or withdrawn for a specific duration. The state or federal government can subject providers to mandatory or subjective exclusions (U.S. Department of Health and Human Services, 2022). Corrective action plans are used to negotiate actions for managed care organizations instead of being penalized. Repeated illegal billing practices can warrant a state to take over the management of managed care organizations. A provider might be forced to revise its contract and include subcontracts specific to illegal billing issues.

References

Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association: JAPhA, 60(6), e60–e65. https://doi.org/10.1016/j.japh.2020.05.011

U.S. Department of Health and Human Services. (2022). Medicaid Fraud Control Units. U.S. Department of Health and Human Services. Retrieved 23 June 2022, from http://oig.hhs.gov/fraud/strike-force/.

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Reimbursement procedures are complex and detailed, especially those associated with government programs such as Medicare. Part of the regulatory requirements of Medicare is to prevent illegal billing practices such as churning, upcoding, and unbundling. For the Week 4 discussion, address the following, keeping in mind the above information:

Illegal Billing Practices

Review the latest enforcement actions on this website. Identify a case where at least one of the following illegal actions was used—churning, upcoding, and unbundling.
What are some of the specific examples of actions taken against providers engaged in these practices?
To support your work, refer to the readings and relevant outside research. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Your initial posting should be addressed at 150-300 words. Submit your document to this Discussion Area by the due date assigned. Be sure to cite your sources using APA format.

Respond to your peers throughout the unit. Justify your answers with examples, research, and reasoning. Follow-up posts need to be submitted by the end of the week.