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Physicians must beware upcoding and false billing practices

Most individuals who endure the years of schooling and training it takes to become a full-fledged medical doctor do so because they want to help people. As with many professionals, despite all of their professional training, physicians are often ill-prepared for many of the realities that come with the job.

Along with the physical, mental and emotional fatigue that comes with treating patients; physicians must also learn to navigate the often convoluted and complicated world of medical billing. For any physician; it’s essential to learn the rules, regulations and intricacies of billing and reimbursement practices with regard to Medicare and Medicaid. Physicians who fail to understand billing and reimbursement requirements related to Medicare and Medicaid may end up unknowingly violating federals laws and facing harsh penalties.


For example, a physician who doesn’t understand Medicare and Medicaid billing and reimbursement policies may violate federals laws and could potentially end up losing his or her medical license, incur hefty civil penalties and be subject to criminal charges.

According to the U.S. Department of Health & Human Services Office of the Inspection General, violations related to upcoding or using billing codes that do not accurately reflect the services rendered are among the most commonly committed by U.S. physicians.
False claims violations may include billing for:

  • services that a patient did not receive
  • unnecessary procedures
  • services performed by "an improperly supervised or unqualified employee"
  • ineffective and extraneous procedures
  • services separately when they should be included under one billing code

Physicians who willfully participate in upcoding or false billing practices or who should have known about such violations may risk losing their medical license and, in cases where criminal charges are brought, their very freedom. For these reasons, physicians who have questions or concerns about potential fraudulent billing practices would be wise to seek the advice and assistance of an attorney.

Source: U.S. Department of Health & Human Services Office of Inspector General, "A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse," Jan. 26, 2016

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