Upcoding: Typically submitting a claim for a service more severe than the actual service provided. For example, submitting a claim for a broken ankle, when the patient was only treated for a sprained ankle.- Cloning: Using an EHR system to automatically generate a more detailed patient observation profile by copying from another patient’s file with similar symptoms to appear as if a more thorough examination was done.
- Phantom Billing: Billing for services never performed. This also affects healthcare costs in the millions of dollars invested in tracking and prevention.
- Inflated Hospital Bills: Gross overcharges for procedures and/or on equipment used on medical bills. For example, $1,500 surgical screws or $500 Tylenol pills.
- Service Unbundling or Fragmentation: Billing for multiple procedures separately, that should have been billed together in a bundle in order to forgo the bundled rate and increase profit.
- Self-Referrals: When a provider refers themselves or a partner provider to perform a service, usually for a financial incentive.
- Repeat Billing: Billing twice for the same procedure, supplies or medications.
- Length of Stay: Charges for days not in the provider facility. Most hospitals will charge for the day you arrived, but not for the day you left.
- Correct charge for type of room: For example, if you were in a shared room, make sure you’re not being charged for a private one.
- Time in OR: Some hospitals charge based on an “average” time needed to perform an operation instead of the actual operation time.
- Keystroke Mistake: Entering incorrect codes, resulting in significant overcharges or in some cases an undercharge.
- Cancelled Service: Occasionally a medication, procedure or service that was prearranged and then canceled later but is still charged.
- No Medical Value: Claims submitted for payment for poor service that resulted in a decline in patient’s health.
- Standard of Care: Billing for services in which the provider failed to meet quality standards of care and provide preventative actions to safeguard patient’s health.
- Unnecessary Treatment: When a provider performs unnecessary tests in order to bill for them.
Here we highlight 15 types of medical billing fraud and abuse affecting the US healthcare system