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8 Tips to Prevent Filing False Claims That Could Cost Your Practice $$

Jun 8, 2021 7:45:00 AM

Are you auditing cases at your practice? Almost daily, we read about fines as well as the sentencing of healthcare providers over the submission of fraudulent claims – both intentionally and unintentionally. We are also noticing increased scrutiny of telehealth thanks to the COVID-19 pandemic.

Government Collects Billions in Fines From Practices Each Year

Under the False Claims Act, the government can recover up to three times its actual damages, plus penalties of $11,665 to $23,331 for each false claim. These minimum and maximum per-penalty fines have more than doubled since 2015 – and they can quickly drain a practice’s bank account depending on the number of violations.

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For the fiscal year 2020, the Department of Justice (DOJ) collected more than $2.2 billion from False Claims Act violations, down from $3 billion the year before – the vast majority of the fines coming from the healthcare industry. The largest of the 2020 fines was $591 million for a kickback scheme involving a pharmaceutical company.

Among providers, United Health Services incurred the largest 2020 fine – $117 million for allegations that its inpatient psychiatric hospitals and residential psychiatric and behavioral treatment facilities knowingly submitted false claims for inpatient behavioral health services that were not reasonable or medically necessary and/or failed to provide adequate and appropriate services to its patients.

That may be an extreme case, but since enactment in 1986, the False Claims Act has resulted in a total of about $65 billion in penalties, an average of nearly 2 billion annually.

Meanwhile, the federal government has already finalized at least 110 cases in 2021 against fraudulent providers in many specialties. The prospects of enormous fines can be frightening for providers and the survival of their practices and livelihoods, but you can avoid such crippling penalties by learning how to proactively identify errors and prevent potentially fraudulent claims.

These Medical Coding Tips Could Spare You Thousands in Fines

Here are some tips regarding common coding and documentation errors that often lead to costly false claims each year:

  • Incorrect CPT time-related codes for psychotherapy are frequently cited by the Office of Inspector General (OIG) in their audits. Why? Because even though a patient might be in your office for an hour, the documentation of the start and stop time of psychotherapy treatment is usually less than an hour. Emphasize accuracy in time actually spent with a client for each session.

  • Documentation of the accurate start and stop time and the service provided are crucial to avoid potential fraud issues.

  • Several providers have been cited by the OIG and DOJ for billing more hours than are possible in a single day. Some days it may feel as if we have been at work for 24 hours, but the reality on the claims form is significantly different.

  • Documentation that a lower-licensed provider rendered services but then billed inaccurately as a higher-licensed provider is also noted in OIG and DOJ audits.

  • The level of care rendered and billed should correspond to the documentation in the chart. The care rendered should also correspond to the treatment plan. For example, group therapy can not be billed as individual therapy.

  • Documentation of medical necessity is vital to ensure correct coding and billing.

  • Determine your state’s laws about who can and cannot submit claims. Providers have been cited by the OIG and DOJ and have had to pay back claims when an unlicensed or lower-licensed provider rendered services.

  • Providers have been cited for billing answered texts or emails or reviewing lab work as a face-to-face or telehealth visit. Avoid this fraudulent practice.

Bad actors will always exist in any industry. Enacting basic auditing at your practice can help you identify issues and get on a path to correction before it becomes a larger and potentially most costly issue. Auditing cases also allows you to better identify best practices, training opportunities, and areas of improvement with staff.

For More False-Claim Protections, Check Out InSync EHR Software

If you are looking for an extra layer of protection when it comes to false claims, the InSync Healthcare Solutions platform provides auditing capabilities to help you achieve this goal. How?

The InSync EHR Automates Medical Billing 

automated medical billing rules engine software by insync healthcare solutionsWatch Video

To find out, schedule a custom demo now with one of our experts. We're happy to answer questions and explain how our system can increase workflow efficiencies in your practice – and help prevent you from filing false claims that could end up costing you a bundle. 


Beth Socoski

Written by Beth Socoski

With more than 20 years of experience in healthcare, compliance, and security, Beth brings integrity, respect, and a world of valuable and applicable knowledge to the InSync team. In addition to three master’s degrees, she has multiple accreditations in healthcare, compliance, ethics, and leadership. As a scholar at heart, she is steadfast in her desire to remain current on compliance requirements – and to share that information in language that is easily understood by all.