Examples of Potentially Fraudulent, Wasteful, or Abusive Billing (not an inclusive list)
Backfilling: Billing for part of the global fee before the claim is received for the actual global code.
Billing for services not rendered: Billing for services or supplies that were not provided to the member.
Billing for unauthorized services or equipment: Billing for ancillary, therapeutic or other services without a required physician’s order.
Billing while ineligible: Billing for services aftercare provider’s license has been revoked/restricted or after a care provider has been debarred from a government benefits program for fraud or abuse.
Double billing: Billing more than once for the same service.
Falsified documents: Submitting falsified or altered claims or supporting claims with falsified or altered medical records and/or supporting documentation.
Looping: Submitting claims for various family members when only one member is receiving services.
Misrepresentation: Misrepresenting the diagnoses and/or services provided to obtain higher payment or payment for non-covered services.
Patient brokering: Using “brokers” who offer money to subscribers for the use of their ID cards.
Phantom billing: Billing by a “phantom” or non-existent care provider for services not rendered.
Unbundling: Billing each component of a service when one comprehensive code is available.
Up-coding: Billing at a higher level of service than was actually provided.
Waiver of copay: Choosing not to collect copayments or deductibles as part of the payment Agreement.