COMPLIANCE: Spot Potential Fraud on Your Provider's Claims? Check Documentation, Then Contact Provider

Why This Topic Matters

Improper claims can create compliance, ethical, and organizational risk. Understanding how to compare billed services to documentation and when to escalate concerns helps reduce the chance of billing errors, missed fraud indicators, or inappropriate handling of suspicious activity.

Article Sections

1. Recognizing suspicious claim activity

   Introduces the compliance environment and the general problem of unusual billing patterns. It frames why coders may need to pay closer attention to claims and supporting records.

2. How can you recognize fraud?

   Discusses general fraud-identification resources and the role of government oversight materials. The section focuses on broad awareness of fraud and abuse concerns.

3. Take action

   Explains the importance of comparing claims with documentation and involving internal leadership when something does not align. It addresses the general process of escalating a concern.

4. Examine Non-Timed Codes

   Covers the difference between time-based billing and other kinds of evaluation and management services. It discusses why not all claim review issues can be assessed by counting units or minutes.

5. If you do find fraud

   Addresses what to do when a review suggests a real problem and emphasizes internal reporting. It also touches on professional responsibility and ethics.