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Make Your Practice Free from False Claim Billing

by Nathan Zachary
Virtual Doctor Prescriptionbilling

Claim denials are instances where an insurance company refuses to pay out a claim. This can happen for a number of reasons, including if the insurer believes that the claim is not covered by the policy, if the insurer believes that the claim is fraudulent, or if the insurer believes that the claim is not valid or it’s a false claim.

False Claims Billing Act

The False Claims Billing Act is a law that protects consumers from fraudulent billing practices. This law is also known as the Truth in Advertising Act. The False Claims Billing Act prohibits businesses from making false or misleading claims about their products or services. Businesses that violate this law can be fined up to $10,000 per violation. The False Claims Billing Act is enforced by the Federal Trade Commission (FTC).

This law allows the government to file a civil lawsuit against any person or entity that has submitted false or fraudulent claims for payment from the government. The False Claims Billing Act also imposes harsh penalties on those who are found guilty of fraud, including a fine of up to $11,000 for each false claim, as well as up to three times the amount of money that was fraudulently obtained.

How much can be the Penalty?

The False Claims Act imposes harsh penalties on persons who are found to have submitted false claims to the government. The government can impose treble damages, which is three times the amount of damages it has incurred, plus civil penalties of between $5,500 and $11,000 for each false claim.

You should be aware that the government can also initiate a qui tam action against you. This means that an individual can sue on behalf of the government and get a portion of the recovery. This portion could be as much as 30% if the government intervenes.

The act also contains a provision making it a felony to retaliate against an employee who has filed a suit or provided information to the government under the act.

False Claims in Medical Billing, Examples

Some common examples of false claims in medical billing include:

-Billing for services that were not provided

-Upcoding (billing for a more expensive service than the one that was provided)

-Unbundling (billing for each component of a procedure separately instead of billing for the procedure as a whole)

-Billing for a brand name medication when a generic was provided

-Double billing (billing for the same service twice)

-Billing for a higher level of care than was actually provided

Medical Billing Fraud

The billing fraud is the billing of unnecessary medical services. This is the type of fraud that is most commonly associated with healthcare fraud and it is the type of fraud that we are most often able to investigate.

In this type of fraud, the provider will bill for medical services that were never provided. This can be done in a number of different ways. One example of this is billing for a procedure that was never actually performed. For example, the provider may bill for a colonoscopy when the patient actually was only given a rectal exam.

Another way this type of fraud can be perpetrated is by billing for more services than were actually provided. This might happen when the provider bills for an MRI but only gives the patient an X-ray. However, this type of fraud can sometimes be hard to detect.

In some cases, we have seen providers bill for services that they claim they provided when they actually did not. For example, a provider might bill for a physical when he actually only looked at the patient’s medical records.

What Makes Something a “False” Certification Under the False Claims Act?

A certification is made in connection with a claim for payment when the individual submitting the claim makes specific representations about the goods or services provided, or the compliance with certain statutes or regulations. A false certification can be either express or implied. An express certification is made when the individual submitting the claim specifically represents that he or she has complied with all applicable statutes and regulations. An implied certification is made when the claim does not expressly state compliance, but compliance is necessary in order for the claim to be paid.

A certification can be false even if the individual submitting the claim did not know that the certification was false. For example, if an individual submits a claim for payment for goods or services that were not actually provided, the individual has made a false certification, even if he or she did not know that the goods or services were not actually provided.

The False Claims Act imposes liability on any individual or entity who knowingly submits a false claim for payment to the government. The Act also imposes liability on any individual or entity who knowingly makes a false statement or misrepresentation of material fact in order to get a claim paid by the government.

How can I avoid violations of the False Claims Act?

There are different ways by which you can avoid violations of the False Claims Act. The first thing is you need to be aware and fully understand the rules related to the goods and services being billed. Secondly, when you observe any problem related to billing, you should instantly notify the compliance officer and supervisor. It is required that you act immediately if you recognize any problem and solve the issue before its gone worst.

Potential actions include:

  • Making changes to prevent the problem from continuing
  • Making arrangements to repay any overpayments
  • When appropriate, disclosing the problem to appropriate state and federal officials

Conclusion The false claims in billing has severe consequences and can lead to even worst. To prevent such mistakes and avoid false claims you need to get the help of an expert. So, we are here to help you avoid the big risks. Also, reduce the claim denials and improve your practices tremendously.

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