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Seven Common Forms of Medical Fraud

Updated on October 5, 2014

Fraud is intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes it known that the deception could result in some unauthorized benefit to himself/herself or some other person. Fraud involves both deliberate intention to deceive and an expectation of an unauthorized benefit.

It is fraud if a claim is filed for a service rendered to a Medicare patient when that service was not actually provided. Medicare patients sign a standing approval, which is kept on file in the medical office. Having a standing approval is convenient for the patient ad for the coding staff. But a standing approval also makes it easy for an unscrupulous person to submit charges for services never provided. Therefore, the standing approval is abused. Medicare fraud is a widespread problem.

The violators may be a physician or other practitioner, a hospital or other institutional provider, a clinical laboratory or other supplier, an employee of a provider, a billing service, a beneficiary, a Medicare carrier employee, or any person in a position to file a claim for Medicare benefits. Medical coders filing Medicare claims have to be careful about the claims they submit. It is important to validate that the service was provided by consulting the medical record or the physician.


  • Billing for services not furnished
  • Misrepresenting a diagnosis to justify a payment
  • Soliciting, offering, or receiving a kickback
  • Unbundling, or “exploding,” charges
  • Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment
  • Billing for additional services not furnished as billed - up coding
  • Routine waiver of co-payment

The CMS administers the Medicare program. CMS’s responsibilities include managing claims payment, overseeing fiscal audit and /or over payment prevention and recovery, and developing and monitoring the payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery. Within CMS’s Bureau of Program Operations is the Office of Benefits Integrity (OBI), which oversees Medicare’s payment safeguard program related to fraud, audit, medical review, the collection of over payments, and the imposition of civil monetary penalties (CMP’s) for certain violations of the Medicare law. The Office of the Inspector General (OIG), Department of Health and Human Services, outlines the ways in which the Medicare program is monitored to identify fraud and abuse. Specific Regulation in the Internet-Only Manual (IOMs) for providers and carriers to follow. These regulations will help the Coder to know what is allowable and what fraud and abuse are. For example: Using another person’s Medicare card to obtain medical care is fraud.

Medical Coders submitting Medicare claims are the ones whom the CMS holds responsible for submitting truthful and accurate claims. If you are unsure about a charge or a request, check with the physician or other supervisory personnel to ensure that you are submitting the correct charges for each patient. In this way, you protect the Medicare program, your facility, and yourself.

Reference: 2010 STEP-BY-STEP MEDICAL CODING by Carol J. Buck

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