When medical billing and coding errors occur, it can be the beginning of a huge set of problems. Claims might not be paid, they could be paid incorrectly or to the wrong provider, or fraud and abuse investigations can start to occur. The outcome can be simple, or the provider can be charged with violations of the False Claims Act and fined $10,000 per error.
Primary Error Outcome
The claim is usually denied if the claim does not show medical necessity or if the diagnosis does not correlate to the procedure.
Paid Wrong Providor
If the physician billing number is wrong, the wrong provider can be paid and reported incorrectly to IRS.
Paid Incorrectly
If too many or too few units, days of services or number of products are billed, the payment will be underpaid or overpaid.
Abuse
Billing abuse occurs when the same type of error is made continuously and the provider does nothing to correct the error, even when the provider knows he should educate the biller to bill correctly.
Fraud
Billing fraud occurs when a provider has knowingly billed incorrectly from the beginning and does not care that it is wrong. Common billing fraud is billing for services never rendered, the number of units billed being inflated in number or stealing patients' insurance identification numbers.
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