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What triggers a Medicare or Medicaid fraud investigation?

The Office of the Inspector General is serious about prosecuting instances of Medicare and Medicaid fraud. Not only is a national concern that affects millions of Americans, it's also a political "hot button" issue. Nobody wants to look soft on the issue -- so prosecutors can be very aggressive.

If you're a physician or medical billing specialist, it's important to understand that even unintentional mistakes can trigger a Medicare or Medicaid fraud investigation. What are the most common billing issues that will start that particular ball rolling?

1. Providing services or items that aren't medically necessary

There are limits on what these medical programs will cover. If a procedure or treatment isn't considered reasonable or necessary for a specific condition, it can trigger an inquiry. Even if it is a standard treatment for a specific condition, it's important to make sure that you have the documentation to support a diagnosis and good records of how frequently the treatment was provided.

2. Separately billing items that should be bundled together

This allows unscrupulous providers to charge more than they should for a specific procedure. One common trick is to claim that medical treatment was given during two separate visits -- which lets the provider charge double. For example, a provider might claim that a patient received steroid shots in his or her knees on separate visits instead of during the same visit.

3. Billing twice for the same procedure

This happens sometimes by accident and sometimes on purpose. It's especially common when a patient has private insurance in addition to his or her Medicare. That's why billing offices need to be especially careful to bill patients with dual coverage correctly.

4. Billing for more expensive services than what was provided

This practice is known as "upcoding." It can be hard to catch, but patients themselves sometimes catch on and turn providers in. So do disgruntled employees or whistleblowers.

One of the worst positions you can be in is behind the crosshairs of a medical billing investigation. If you suspect that you are being targeted for a fraud investigation, it's wise to get legal advice as soon as possible.

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